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Biomedical subjects

P Gajdos

Publications and source records attributed to P Gajdos.

At least 19 recordsLinked to original sources
PubMed2006

Intravenous immunoglobulin for myasthenia gravis.

BACKGROUND: Myasthenia gravis is an autoimmune disease in which autoantibodies interfere with neuromuscular transmission. As with other autoimmune diseases, people with myasthenia gravis would be expected to benefit from intravenous immunoglobulin. OBJECTIVES: The objective of this review was to examine the efficacy of intravenous immunoglobulin for treating exacerbations of myasthenia gravis or for chronic myasthenia gravis. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register (March 2005) and MEDLINE (January 1966 to March 2005) using 'myasthenia gravis' and 'intravenous immunoglobulin' as the search terms. SELECTION CRITERIA: We included all randomised or quasi-randomised trials in which intravenous immunoglobulin was compared with no treatment, placebo or plasma exchange, in people with myasthenia gravis. DATA COLLECTION AND ANALYSIS: One author extracted the data and the two others checked these data and the source from which they were derived. For methodological reasons, no formal meta-analysis was performed. MAIN RESULTS: We identified five randomised controlled trials, all of which investigated short-term benefit. The first study of 87 participants with exacerbation found no statistically significant difference between immunoglobulin and plasma exchange after two weeks. The second study of 12 participants with moderate or severe myasthenia gravis treated in a crossover design trial found no statistically significant difference in the efficacy of immunoglobulin and plasma exchange after four weeks. The third study with 15 participants with mild or moderate myasthenia gravis found no statistically significant difference in efficacy of intravenous immunoglobulin and placebo after six weeks. The fourth study terminated early. It included 33 participants with moderate exacerbations of myasthenia gravis and showed no statistically significant difference in the efficacy of intravenous immunoglobulin and methylprednisolone. The fifth trial including 173 people with myasthenia gravis exacerbations, showed no superiority of intravenous immunoglobulin 1 g/kg on two consecutive days over intravenous immunoglobulin 1 g/kg on a single day. AUTHORS' CONCLUSIONS: In severe exacerbations of myasthenia gravis, one randomised controlled trial did not show a significant difference between intravenous immunoglobulin and plasma exchange. Another showed no significant difference in efficacy between 1 g/kg and 2 g/kg of intravenous immunoglobulin. A further trial showed no significant difference between intravenous immunoglobulin and oral methylprednisolone. In chronic myasthenia gravis, there is insufficient evidence from randomised trials to determine whether intravenous immunoglobulin is efficacious. More research is needed to determine whether intravenous immunoglobulin reduces the need for steroids as suggested by two case series.

Humans↗
PubMed2005

Corticosteroids for myasthenia gravis.

BACKGROUND: Although widely accepted as an appropriate immunosuppressive therapy, the efficacy of glucocorticosteroid treatment has only rarely been tested in controlled studies. OBJECTIVES: To assess the efficacy of glucocorticosteroids or adrenocorticotrophic hormone (ACTH) medication in autoimmune myasthenia gravis. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register in July 2004, MEDLINE (from January 1966 to June 2004) and EMBASE (from January 1980 to June 2004). We also checked the bibliographies in reviews and the randomised trials and contacted their authors to identify additional published and unpublished data. SELECTION CRITERIA: From the articles identified we selected those open or controlled studies which allowed us to assess the outcome of treated and untreated patients at definite endpoints. Types of studies: quasi-randomised or randomised controlled trials. TYPES OF PARTICIPANTS: patients with myasthenia gravis of all ages and all degrees of severity. Types of interventions: any form of glucocorticosteroids or adrenocorticotrophic hormone treatment. Types of outcome measures:Primary outcome(1) improvement after at least three months in either the weakest muscles or all muscles. Secondary outcomes(1) proportion of patients improved after at least six months(2) proportion of patients in remission(3) number of episodes of worsening during the first six months(4) acetylcholine receptor antibody titres after at least three months of therapy. DATA COLLECTION AND ANALYSIS: Three authors extracted the data from the selected articles and one other checked them. MAIN RESULTS: A trial of adrenocorticotrophic hormone (43 patients) did not show any advantage compared with placebo for the treatment of ocular myasthenia gravis. Two double-blind trials compared prednisone with placebo for generalised myasthenia gravis. In the first (13 patients), the improvement was slightly greater in the prednisone group at six months. In the second (20 patients) which was a short-term trial, the improvement was significantly greater at two weeks. Two trials compared glucocorticosteroids with azathioprine (41 and 10 patients respectively). In one of these the rate of treatment failure was greater in the prednisone group. In a trial of glucocorticosteroids versus intravenous immunoglobulin (33 patients) no differences in treatment responses were encountered during a treatment period of 14 days. An open trial (39 patients) evaluating different corticosteroid doses revealed a shorter time to improvement in the high-dose group. However only limited evidence can be drawn from the available randomised controlled trials due to numerous and important methodological flaws. AUTHORS' CONCLUSIONS: Limited evidence from randomised controlled trials suggests that corticosteroid treatment offers significant short-term benefit in myasthenia gravis compared with placebo. This supports the conclusions of observational studies and expert opinion. Limited evidence from randomised controlled trials does not show any difference in efficacy between corticosteroids and either azathioprine or intravenous immunoglobulin.

Adrenal Cortex Hormones↗
PubMed2004

[Seronegative myasthenia gravis].

Six to 20 p.cent of patients with generalized myasthenia gravis and 30 to 50 p.cent of those with ocular myasthenia gravis do not have anti AchR antibodies. Strict clinical, pharmacological and electrophysiological criteria are needed for the diagnosis of sero-negative myasthenia gravis. Sero-negative myasthenia gravis is an autoimmune disorder. But thymic hyperplasia is generally absent. Antibodies directed against the muscle receptor of tyrosine kinase (anti MuSK antibodies) were recently demonstrated in 40 to 70 p.cent of patients with sero-negative myasthenia gravis. Sero-negative and sero-positive myasthenia gravis may be clinically very similar. But sero-negative myasthenia gravis may express predominantly severe oculobulbar weakness or mainly neck, shoulder and respiratory muscle weakness. Sero-negative myasthenia gravis is never associated with thymoma. Sero-negative myasthenia gravis responds to immunodulation but perhaps less well than sero-positive myasthenia gravis.

Age of Onset↗
PubMed2004

Association of the gene encoding the delta-subunit of the muscle acetylcholine receptor (CHRND) with acquired autoimmune myasthenia gravis.

The muscle acetylcholine receptor (AChR) is the main target self-antigen in acquired autoimmune myasthenia gravis (MG). Here, we investigated an association of MG with the CHRND gene encoding the delta-subunit of the AChR. Using a microsatellite repeat located in the second intron of the gene, we observed a preferential transmission of the allele 268 in 114 one-generation families with one myasthenic child (Pc=0.0154). This allele was also over-represented in a group of 350 unrelated nonthymoma MG patients (OR=1.78, P=0.038), but not in 84 thymoma patients, compared to 168 healthy controls. Moreover, among nonthymoma patients, those lacking serum anti-titin antibodies appeared to be best associated (OR=2.07, P=0.017). In contrast, there was no distortion in the transmission of a single-nucleotide substitution polymorphisms (SNPs) in the 3' untranslated region of CHRND nor in that of two SNPs located in the closely linked CHRNG gene, 4.5 kb telomeric to CHRND. The data warrant a detailed investigation of CHRND polymorphism in MG patients.

Child, Preschool↗
PubMed2004

Genetic control of autoantibody expression in autoimmune myasthenia gravis: role of the self-antigen and of HLA-linked loci.

Autoantibodies against the muscle acetylcholine receptor (AChR) play an essential role in the pathophysiology of autoimmune myasthenia gravis (MG). Their serum titers, however, vary considerably among patients. Our aim was to investigate whether their variation might be explained by genetic factors. Using different methods, we have obtained strong evidence for a three-locus association influencing autoantibody titers in MG patients with thymus hyperplasia or with a normal thymus. Two of the loci, one encoding the AChR alpha-subunit, the other encoding the alpha-chain of the class II antigen-presentation molecule, HLA-DQ, demonstrated interaction to determine high autoantibody titers. The third locus was associated with the 8.1 ancestral HLA haplotype. It exerted an additive effect and it is postulated to have a nonantigen specific immunoregulatory function. Our study demonstrates for the first time that polymorphism of an autoantigen gene may quantitatively modify the immune response against it. Altogether, the data lend support to a three-gene model to explain autoantibody expression in a subset of MG patients.

Autoantibodies↗
PubMed2004

[Consolidation of therapy of acute myeloid leukemia with the AML-BFM 93 protocol in children in the Czech Republic].

BACKGROUND: Acute myeloid leukemia (AML) in children is rare. Although more resistant to chemotherapy than acute lymphoblastic leukemia, its responsiveness and survival rates have considerably improved during the last 15 years by virtue of intensification of chemotherapy and due to the better supportive care. Relapses still remain the main cause of treatment failure. Management of children with AML was unified in the Czech Republic in 1993 according to AML-BFM 93 Study protocol. METHODS AND RESULTS: Treatment results were evaluated in 61 patients, of whom 45 (73.8%) achieved complete remission. Five-year event-free-survival (EFS) was found in 42.3%, and overall survival was 45.3%. Prognosis of the standard-risk patients was significantly better than in the high-risk group (EFS 62.5% vs. 29.7%, p = 0.03). The most important prognostic factor was the early treatment response. Compared to chemotherapy, allogeneic stem-cell transplantation did not significantly improve the outcome of high-risk patients. CONCLUSIONS: Treatment results of children with AML in the Czech Republic are comparable to those achieved by leading leukemia study groups in the world. The aim of the next study is to increase the complete-remission rate by reducing early deaths.

Acute Disease↗
PubMed2003

Intravenous immunoglobulin for myasthenia gravis.

BACKGROUND: Myasthenia gravis is an autoimmune disease. In up to 90 per cent of cases IgG autoantibodies to the nicotinic acetylcholine receptor are detectable which mediate the neuromuscular transmission disorder. As with other autoimmune diseases, patients would be expected to benefit from intravenous immunoglobulin. Case series and two randomised controlled trials suggest that intravenous immunoglobulin may be beneficial. OBJECTIVES: The objective of this review is to examine the efficacy of intravenous immunoglobulin for treating exacerbations of myasthenia gravis or for chronic myasthenia gravis. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register (21 July 2002) and MEDLINE (January 1966 to July 2002) using 'myasthenia gravis' and 'intravenous immunoglobulin' as the search terms. SELECTION CRITERIA: All randomised or quasi-randomised trials in which intravenous immunoglobulin was compared with no treatment, placebo or plasma exchange, in people with myasthenia gravis who were diagnosed by an internationally accepted definition. DATA COLLECTION AND ANALYSIS: One author extracted the data and the two others checked these data and the source from which they were derived. For methodological reasons, no formal meta-analysis was performed. MAIN RESULTS: We identified four randomised controlled trials (147 participants in total), all investigating short-term benefit. In the first study of 87 people with myasthenia gravis exacerbation, comparing intravenous immunoglobulin and plasma exchange, there was no statistically significant difference between the efficacy of the two treatments after two weeks. In the second study 12 people with moderate or severe myasthenia gravis were treated in a cross-over design trial with intravenous immunoglobulin or plasma exchange: no statistically significant difference in the efficacy of the two treatments was found after four weeks. In the third study 15 people with mild or moderate myasthenia gravis received intravenous immunoglobulin or a placebo: no significant difference in efficacy of intravenous immunoglobulin or placebo was found six weeks after treatment. The last study, which included 33 people with moderate exacerbations of myasthenia gravis, compared intravenous immunoglobulin and methylprednisolone and showed no statistically significant difference in the efficacy of the two treatments. REVIEWER'S CONCLUSIONS: One randomised controlled trial did not show a significant difference between intravenous immunoglobulin and plasma exchange for treatment of severe exacerbations of myasthenia gravis. There is no evidence from randomised controlled trials to determine whether intravenous immunoglobulin for moderate or severe myasthenia gravis improves functional outcome or has a sparing effect on steroid dosage, nor is there sufficient evidence to favour intravenous immunoglobulin over steroids in moderate exacerbations. Further randomised controlled trials are needed.

Humans↗
PubMed2003

Standards of measurements in myasthenia gravis.

Valid and reliable measurements of muscle impairment are needed to assess therapeutic efficacy in patients with generalized myasthenia gravis. Several muscle scoring systems have been proposed for assessing muscle strength in such patients. The aim of the present study is to assess the validity and interobserver agreement of these muscle scores.

Activities of Daily Living↗
PubMed2003

[Improved results in children with acute lymphoblastic leukemia treated with the ALL-BFM 90 protocol in the Czech Republic].

BACKGROUND: Prognosis of children with acute lymphoblastic leukaemia (ALL)--the most common cancer in childhood, has improved remarkably over the last 40 years. The authors report the treatment outcome in children with ALL cured according to ALL-BFM 90 Study protocol in the Czech Republic during the first half of nineties. METHODS AND RESULTS: Children aged 0-18 years were included into the study in 10 centers between 1990 to 1996. Patients were classified into standard-risk (SR), medium-risk (MR) and high-risk (HR) group according to initial leukaemic burden, early treatment response, and genotype of leukaemia. Duration of the chemotherapy was two years. Treatment results were evaluated in 352 children. With a median follow-up of 7.3 years, event-free-survival (EFS) was 71.3% and overall survival 76.4%. EFS was 80.3%, 74% and 28.2% in SR, MR and HR group, respectively. Relapse was diagnosed in 17.8% of the patients. CONCLUSIONS: The treatment outcome of children with ALL improved significantly (p = 0.0045) compared to the previous study ALL-BFM 83 (EFS 62%). These results are comparable to those achieved by leading leukaemia study groups in the world.

Adolescent↗
PubMed2003

[Myasthenia gravis and pregnancy. Report on 13 cases].

OBJECTIVES: To evaluate our experience of myasthenia during pregnancy. MATERIALS AND METHODS: Retrospective study in a tertiary care university hospital including pregnant women affected by myasthenia gravis and who delivered in the obstetrical tertiary center. Medical and delivery reports were analyzed. RESULTS: Between 1994 and 2002, 12 women, age 31 (25-36), delivered 14 children. One women delivered twice, and there was one twin pregnancy. Clinical symptoms of myasthenia worsened in five. One was admitted twice to the intensive care unit during her pregnancy. Two were admitted to intensive care unit during the first month of post-partum. Gestational age at birth was 39.3 weeks (38-40.6), all birth weights were normal: 3329 g (2660-4520). Six women delivered vaginally, two by instrumental extraction and five by cesarean section. Apgar score was normal for all infants: 9/10. The level of anti-acetylcholine receptor antibodies (anti AchR) was high: 36.4 nM/L (0-46.8) (normal below 0.6 nM/L), but was not related to neonatal outcome. Three children presented neonatal myasthenia. CONCLUSION: We recommend obstetrical monitoring in tertiary centers for pregnant women with myasthenia gravis because of the risk of neonatal myasthenia. Measurement of anti-acetylcholine receptor antibodies may be useful. Pediatric and maternal observation is necessary in the first days of post partum.

Adult↗
PubMed2002

[Effect of amifostine on reducing acute toxicity of megachemotherapy of tumors in children].

BACKGROUND: Amifostine (WR-2721, Ethyol) is a chemoprotective agent. There is little experiences with amifostine application in megachemotherapy in children. We evaluated amifostine effect on the reduction of the acute toxicity. METHODS AND RESULTS: Retrospective comparison of patients who received amifostine with the control group (72 vs. 72). Amifostine 750 mg/m2 was given 15 minute before cytostatic dose and regularly each eight hours if we administered cytostatics continuously. Megachemotherapy schedule included melfalan, carboplatin, cyklophosphamid, vepesid, busulfan, thiotepa and karmustin. Type of graft: peripheral stem cells 56 vs. 29, bone marrow 8 vs. 30, combination 8 vs. 13. Nonhematological toxicity: mucositis p = 0.047, hepatotoxicity p < 0.001, nephrotoxicity p = 0.005. Hematological toxicity: engraftment D + 12 vs. D + 15 (p < 0.001), amount of erythrocyte transfusions 3 vs. 6 (p < 0.001), platelet transfusions 7 vs. 9 (p = 0.06), days when number of platelets reaches 20,000 without substitution D + 15 vs. D + 22 (p < 0.001). The only statistically difference was in the in total amount of platelets (p = 0.032), when we calculated patients, who received peripheral stem cells. Number of hospitalization days 14 vs. 18 (p = 0.016), days with antibiotics 14 vs. 18 (p = 0.016), number of febrile days 6 vs. 7 (p = 0.51). CONCLUSIONS: Amifostine reduces mucosal, liver and kidney damage. The graft type could affect hematological results.

Adolescent↗
PubMed2002

Plasma exchange for myasthenia gravis.

BACKGROUND: Myasthenia gravis is an autoimmune disease mediated by auto-antibodies direct against the nicotinic receptor for acetylcholine. Patients would be expected to benefit from plasma exchange. Non-randomised studies suggest that plasma exchange is beneficial in the short term. OBJECTIVES: To examine the efficacy of plasma exchange in the short and long term treatment of myasthenia gravis. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register (searched 17 July 2002) and MEDLINE (January 1966 to June 2002) for randomised controlled trials using myasthenia gravis as the search term. We checked the bibliographies in reports of randomised trials and contacted one author to identify additional published or unpublished data. SELECTION CRITERIA: Types of studies: All randomised or quasi-randomised studies. TYPES OF PARTICIPANTS: All patients with myasthenia gravis who were diagnosed by an internationally accepted definition. Types of intervention: Treatment with plasma exchange alone or combined with steroids or immunosuppressive drugs. Types of outcome measures: PRIMARY OUTCOME MEASURE: ~bullet~patients treated for exacerbation: change in a specific muscle score after plasma exchange; ~bullet~patients treated for chronic myasthenia gravis: change in a functional scale. SECONDARY OUTCOME MEASURES: ~bullet~patients treated for exacerbation: change in a functional scale and percentage weaned from mechanical ventilation; ~bullet~patients treated for chronic myasthenia gravis: percentage in remission by the end of one year after first plasma exchange; ~bullet~adverse events. DATA COLLECTION AND ANALYSIS: One author extracted the data and the two others checked them. Since there was only one trial no formal meta-analysis was required. MAIN RESULTS: We identified one randomised controlled trial. Improvement in a quantitative muscle score was not significantly greater in patients treated with plasma exchange and prednisone than in patients treated with prednisone alone one month after onset of treatment. More relapses were observed in the plasma exchange and prednisone group in the first year as compared with the prednisone alone group. Problems in recruitment and matching of patients entered into this trial limit the conclusions that can be drawn. On the other hand,experience from many non-randomised studies suggests that plasma exchange is beneficial in myasthenia gravis. Consequently the relative benefits of plasma exchange are still unconfirmed. REVIEWER'S CONCLUSIONS: There are no adequate randomised controlled trials but many case series report short-term benefit from plasma exchange in myasthenia gravis, especially in myasthenic crisis. There are no adequate randomised controlled trials to determine whether plasma exchange improves the long-term outcome for myasthenia gravis. Further research is need to compare plasma exchange with alternative short-term treatments for myasthenic crisis and to determine the value of long-term plasma exchange for treating myasthenia gravis.

Combined Modality Therapy↗
PubMed2001

Linkage of HLA to myasthenia gravis and genetic heterogeneity depending on anti-titin antibodies.

BACKGROUND: MG is an autoimmune disease of the neuromuscular junction. MG with thymus hyperplasia has been associated with, but not genetically linked to, the HLA-DR3 haplotype. OBJECTIVE: To re-evaluate the association of HLA with MG in 656 patients with generalized disease and to test linkage of HLA to MG with thymus hyperplasia. METHOD: Patients were genotyped for HLA-DRB1. Data analysis included case-control comparisons after subgrouping patients by thymus histopathology. The transmission of parental alleles to MG offspring with thymus hyperplasia was studied in simplex families using the transmission/disequilibrium test (TDT) as a test of linkage. RESULTS: MG with thymus hyperplasia was positively associated with DR3 (OR = 4.5, p = 1 x 10(-6)) and negatively associated with DR7 (OR = 0.28, p = 1 x 10(-6)), based on both case-control comparisons and TDT. No association was detected with thymomas. Conversely, patients who lacked thymus anomalies but expressed anti-titin antibodies (ATA) had an increase of DR7 (OR = 2.08, p = 4 x 10(-3)) and a decrease of DR3 (OR = 0.33, p = 9 x 10(-3)). CONCLUSIONS: The authors established linkage of HLA to MG and thymus hyperplasia, defining the MYAS1 locus. Moreover, DR3 and DR7, or closely linked genes, have opposing effects on MG phenotypes. Nonthymomatous patients with ATA may be a pathogenetically distinct subset of MG patients.

Adult↗
PubMed2001

Prognostic factors in unintentional mild carbon monoxide poisoning.

OBJECTIVES: To identify early predictors of recovery from mild carbon monoxide poisoning, and to search for qualitative interactions between subsets of patients and treatment effects. DESIGN AND SETTING: Inception cohort study from a 4-year, randomised, controlled trial, which compared normobaric oxygen therapy to the combination of normobaric plus hyperbaric oxygen therapy in 307 patients. Study was conducted at a hyperbaric oxygen therapy referral centre. PATIENTS AND INTERVENTIONS: Victims of unintentional, non-fire-related, domestic, carbon monoxide intoxication were evaluated if the time elapsed from end of exposure to hospital admission was less than 12 h, the carboxyhaemoglobin level was greater than or equal to 10% or 5% for smoker or non-smoker, respectively, and if they did not suffer a loss of consciousness. One course of hyperbaric oxygen therapy or 6-h normobaric oxygen therapy was given. MEASUREMENTS AND RESULTS: The main outcome measure was status at the 1-month recovery. Of the 307 evaluated patients, 206 (67%, 95%CI: 62%-72%) had recovered at 1 month. None of the patients died or suffered severe sequelae. Apathy and headaches were the main moderate sequelae. The multivariate analysis selected dizziness before admission (OR=1.92, [1.17-3.15], p=0.010) and headaches upon hospital admission (OR=2.14, [1.09-4.17], p=0.026) as jointly associated with persistent neurological symptoms. No significant crossover interaction between each combination of these two predictors and treatment effects was observed. CONCLUSIONS: At 1 month after mild carbon monoxide intoxication, victims who presented with dizziness before hospital admission or headaches upon admission have an increased risk of minor persistent neurological symptoms, but almost all patients could resume their former occupation.

Adult↗
PubMed2001

Anti-titin antibodies in myasthenia gravis: tight association with thymoma and heterogeneity of nonthymoma patients.

BACKGROUND: Titin is the major autoantigen recognized by anti-striated muscle antibodies, which are characteristic of generalized myasthenia gravis (MG). OBJECTIVE: To seek a correlation between anti-titin antibodies and other features of MG patients, including histopathology, age at diagnosis, anti-acetylcholine receptor (anti-AChR), autoantibody titers, and clinical severity. METHODS: A novel, highly specific radioligand assay was performed on a large group of 398 patients with generalized MG. RESULTS: Among thymectomized patients, anti-titin antibodies were present in most patients with thymoma (56/70 [80%]), contrasting with only a minority of patients with thymus atrophy or hyperplasia (17/165 [10%]). They were also present in 64 (41%) of 155 nonthymectomized patients who had a radiologically normal thymus. In these patients and in those who had a histologically normal thymus, anti-titin antibodies were associated with a later age at onset of disease and with intermediate titers of anti-AChR antibodies. After controlling for these 2 variables, disease severity was not significantly influenced by anti-titin antibodies. CONCLUSIONS: Anti-titin antibodies are a sensitive marker of thymoma associated with MG in patients 60 years and younger, justifying the insistent search for a thymoma in MG patients of this age group who have these antibodies. In nonthymoma patients, anti-titin antibodies represent an interesting marker complementary to the anti-AChR antibody titer, identifying a restricted subset of patients. These clinical correlations should prompt further studies to examine the mechanisms leading to the production of anti-titin antibodies.

Adult↗
PubMed2001

Supine fall in lung volumes in the assessment of diaphragmatic weakness in neuromuscular disorders.

OBJECTIVE: To determine whether diaphragmatic function can be determined by noninvasive respiratory indices in neuromuscular disease. DESIGN: Vital capacity (VC) and mouth pressure generated during a maximal static inspiratory effort (Pi max) were measured with patients in both sitting and supine positions. SETTING: Rehabilitation hospital. PATIENTS: Twenty-four patients with generalized neuromuscular disease. MAIN OUTCOME MEASURES: Changes in indices from sitting to supine position were compared with invasive diaphragmatic function indices consisting of transdiaphragmatic pressures during maximal sniff (Pdi sniff) and the ratio of gastric pressure (Pga) increases over transdiaphragmatic pressure (DeltaPga/DeltaPdi) during quiet breathing. RESULTS: The fall in VC in the supine position was greater in the 15 patients who had spontaneous paradoxical diaphragmatic motion (DeltaPga/DeltaPdi < 0) than in the 9 patients who did not. Specificity and sensitivity of a greater than 25% supine fall in VC for the diagnosis of diaphragmatic weakness (DeltaPga/DeltaPdi < 0 and/or Pdi sniff < 30cmH2O) were 90% and 79%, respectively. Stepwise multiple regression analysis of Pdi sniff showed that both the supine fall in VC and Pi max were associated with diaphragmatic weakness (R(2) =.66; p <.0001). These factors contributed 52% and 14% of the Pdi sniff variance, respectively. CONCLUSIONS: Simple VC measurement in the sitting and supine positions may be helpful in detecting severe or predominant diaphragmatic weakness.

Adult↗
PubMed2001

Cardiac variability in critically ill adults: influence of sepsis.

OBJECTIVE: To evaluate, in critically ill adults, factors associated with impaired sympathovagal balance. DESIGN: One-month inception cohort study. SETTING: Twenty-six-bed medical intensive care unit of a teaching hospital. PATIENTS: Critically ill adults with an expected duration of intensive care unit stay of > or =48 hrs were enrolled. Patients with permanent arrhythmia or cardiac pacing were not included. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Sympathovagal balance was assessed on the day after intensive care unit admission by the low-frequency/high-frequency ratio obtained from spectral components of heart rate signal: overall variability, low frequency, and high frequency. RESULTS: Forty-one patients, 13 with sepsis and 28 without sepsis, were assessed. Predictors of low-frequency/high-frequency ratio with the automatic interaction detection method were sepsis and age. Binary logit analysis adjusted for age showed that sepsis remained a strong and independent factor of a low-frequency/high-frequency ratio of <1.50, with an odds ratio of 3.63 (95% confidence interval, 1.47-9.01, p =.005). Use of mechanical ventilation, catecholamines, or sedation did not add any information. The use of the low-frequency/high-frequency ratio in diagnosing sepsis may be supported by a likelihood ratio for low frequency/high frequency <1 at 6.47. CONCLUSIONS: This work suggests that impaired cardiac variability and notably sympathovagal balance (i.e., a low-frequency/high-frequency ratio <1.0) may be a diagnostic test for sepsis.

Adult↗