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PubMed1996

Evaluating a national assessment strategy for urinary incontinence in nursing home residents: reliability of the minimum data set and validity of the resident assessment protocol.

Evaluation of 1 million incontinent American nursing home residents is hampered by both failure to detect incontinence and logistical barriers to diagnostic testing. The nationally mandated Minimum Data Set (MDS) and Resident Assessment Protocol (RAP) were devised to address these deficiencies. Although both instruments are also used in at least 18 other countries, neither has been evaluated. Our goal was to determine the reliability of the MDS and the accuracy of the RAP in predicting the lower urinary tract cause of incontinence. We determined interrater reliability for the 13 MDS items related to urinary incontinence in 123 randomly selected residents of 13 nursing homes in 5 states; forms were completed blindly by 2 nurses from each facility who were trained for a day. The RAP was assessed in 102 representative institutionalized women by blinded evaluation of its diagnostic accuracy compared with the multichannel videourodynamic criterion standard. For the MDS, interrater reliability for incontinence of all grades was excellent (weighted kappa correlation coefficient = 0.90), although reliability was greater at the extremes of measurement than for incontinence of intermediate severity. With the exception of delirium, correlations for the 11 MDS items related to incontinence were 0.65-0.96; for 6 items, correlations were > or = 0.8. The diagnostic accuracy of the RAP, successfully administered to 80% of women, was 70%. The accuracy of the nearly identical algorithm that formed the basis for the RAP was 84%. Importantly, serious misclassifications were not observed for either the RAP or the algorithm. Although its definitions should be modified slightly, the MDS appears to be feasible and reliable when administered by trained staff. In women, the diagnostic accuracy and safety of the RAP are good-particularly when administered as instructed-but the original, sex-specific algorithm is preferable. Together, the MDS and modified RAP provide a useful, stepwise, and non-urodynamically based strategy to guide evaluation and therapy of incontinence in this setting.

Aged↗

PubMedDate not supplied

Serum antibody in rheumatoid arthritis reactive with a cell-associated antigen. Demonstration by precipitation and immunofluorescence.

A cell-free extract of human diploid B lymphocytes (Wil2) in continuous culture was used as the source of antigen in immunodiffusion to detect a precipitating antibody referred to as rheumatoid arthritis precipitin (RAP) in sera of patients with rheumatoid arthritis (RA). The prevalence of RAP was determined in various arthritides and other connective tissue diseases. It was found in 67% of patients with seropositive RA and in 62% of patients with Sjögren's syndrome associated with RA. But its frequency was lower in many other connective tissue diseases, including seronegative RA and Sjögren's syndrome without associated RA. Matching sera and synovial fluids from patients with seropositive RA were also studied. Differences in serum and synovial fluid RAP titers were demonstrated, but generally when RAP was present in serum, it was also present in synovial fluid and vice versa. Indirect immunofluorescence (IF) with Wil2 cells as substrate was used to demonstrate RAP and to determine morphologically the nature of the reactive cellular antigen. When cells were treated with commonly used fixatives, little or no staining with RAP positive sera was observed. This outcome was shown to be the result of the extreme solubility of the cellular antigen reactive with RAP. The antigen was retained best in a reactive form in Wil2 cells after fixation of cells with dry heat at 37 degrees C for 30 minutes, and it was demonstrated by IF staining as small round granules distributed in the nucleus and cytoplasm. IF was also employed to demonstrate that RAP is immunoglobulin belonging to IgG and IgM classes and not to IgA or IgD.

Antibodies↗

PubMed2006

Functional characterization of a soluble gp130 isoform and its therapeutic capacity in an experimental model of inflammatory arthritis.

OBJECTIVE: Soluble gp130 is the naturally occurring antagonist of the interleukin-6 (IL-6)/soluble IL-6 receptor (sIL-6R) complex and selectively inhibits IL-6 trans-signaling. Several isoforms of soluble gp130 have been identified, including an autoantigenic form termed gp130-RAPS (for gp130 of the rheumatoid arthritis antigenic peptide-bearing soluble form) that is present in the serum and synovial fluid of patients with rheumatoid arthritis. The aim of this study was to evaluate the functional properties of gp130-RAPS. METHODS: To define a role for gp130-RAPS in arthritis, a recombinant version was generated using a baculovirus expression system, and its activities were tested in vitro and in vivo. RESULTS: Gp130-RAPS was shown to bind with high affinity to the stable IL-6/sIL-6R complex, hyper-IL-6, and to effectively modulate leukocyte migration in murine acute peritonitis. A single intraarticular injection of gp130-RAPS suppressed chronic antigen-induced arthritis in association with a reduction in local activation of signal transducer and activator of transcription 3. Although gp130-RAPS contains the previously identified autoantigenic sequence Asn-Ile-Ala-Ser-Phe (NIASF), no increase in the prevalence of anti- gp130-RAPS antibodies was observed in serum or synovial fluid obtained from patients with rheumatoid arthritis. CONCLUSION: The use of inhibitory antibodies to block IL-6 responses has shown considerable clinical promise. However, the results presented herein suggest that selective targeting of IL-6 trans-signaling may represent a viable alternative to this strategy. In this respect, our present results suggest that the soluble gp130 isoform gp130-RAPS may be useful in the treatment of chronic inflammatory arthritis.

Animals↗

PubMed1997

Rapamycin potentiates dexamethasone-induced apoptosis and inhibits JNK activity in lymphoblastoid cells.

The immunosuppressant rapamycin (RAP) potentiated apoptosis of the murine T lymphoblastoid cell line S49 induced by dexamethasone (DEX), while RAP by itself did not induce apoptosis of the cells. FK506, in contrast, had no effect on DEX-induced apoptosis; moreover, an excess of FK506 reversed the potentiation of apoptosis by RAP, indicating that RAP exerts its effects through binding to FKBP. Both RAP and FK506 enhanced the MMTV promoter activity by dexamethasone, suggesting that the potentiation of apoptosis is not likely explained by the selective enhancement of transcriptional activity of the glucocorticoid receptor. Of interest, the basal activity of c-Jun kinase (JNK), whose activation has been recently suggested to be involved in cell survival signals in lymphocytes, was reduced by RAP in S49 cells. The reduction of JNK activity by RAP was reversed by the addition of an excess of FK506. In summary, we demonstrate for the first time that RAP has the ability to inhibit JNK activity in lymphocytes where the drug enhances apoptosis.

3T3 Cells↗

PubMed1998

Helicobacter pylori and hypergastrinemia in children with recurrent abdominal pain.

Recurrent abdominal pain (RAP) is a significant problem in the pediatric population, and there has been much recent interest in the role that Helicobacter pylori (Hp) might play in this disorder. In this case control study, the authors aimed to determine whether Hp is an agent responsible for RAP, and to assess fasting gastrin concentrations in children with and without RAP in the Hp-positive and -negative groups. The study was conducted in 42 patients with RAP and 50 healthy children attending routine day-case surgery as a control group, aged 3 to 15 years, over a 12-month period. Of the 42 children with RAP, 30 were seropositive (71.4%) for Hp IgG, and of 50 children in the control group, 32 were seropositive (64%) for Hp IgG (P > 0.05). We found that Hp infection was as high in healthy children as in children with RAP. The mean fasting gastrin levels in 62 Hp-seropositive children (60.4 ng/l) were not different from those in 30 Hp-seronegative children (57.3 ng/l) and those in 42 children with RAP (58.2 ng/l) were also not significantly different from those in 50 healthy children (62.9 ng/l). Thus, no association between childhood Hp infection, hypergastrinemia, and RAP was found in our Turkish population.

Abdominal Pain↗

PubMed2002

Recurrent abdominal pain and headache--psychopathology, life events and family functioning.

We assessed the psychopathology of children and adolescents with Recurrent Abdominal Pain (RAP) and tension-type headaches (TTH), the psychopathology and Expressed Emotion (EE) of their mothers and family functioning. Additionally, we assessed the relationship of negative Life Events (LE) to RAP and headaches. Sixty-nine children and adolescents with either RAP or headaches, and their mothers were examined and compared to controls. Of the children with RAP or headache, 81.6% and 83.9% respectively carried a psychiatric diagnosis, primarily anxiety or depressive disorder, in contrast to 15% of controls. Mothers of patients with RAP showed more symptoms of anger and hostility than controls. Index mothers had higher EE than control mothers. More problems were reported in the families of patients with RAP. Families of patients with headache were similar to those with RAP but differed from controls in terms of behaviour control and general functioning. More negative LE were experienced by both index groups. If psychological intervention is decided for certain children with RAP or TTH, it should address their depression, anxiety, the impact of negative LE and family functioning.

Abdominal Pain↗

PubMed2006

Recurrent abdominal pain: what determines medical consulting behavior?

Recurrent abdominal pain (RAP) is associated with increased health care visits and school absences. In adults suffering from functional pain, psychosocial factors determine illness behavior and we aimed to investigate its role among children. A community sample of 40 RAP consulters, 41 RAP nonconsulters, and 36 pain-free controls and their mothers completed questionnaires on GI and non-GI symptoms, school absences, psychological symptoms, coping, self-esteem, and behavioral and cognitive responses to RAP. T-tests showed significant differences between RAP and controls in (1) GI and non-GI symptoms and school absences, (2) child distress and passive coping, and (3) mother's IBS severity, somatization, and fears about RAP. RAP consulters reported the same levels of GI symptoms and psychological distress as nonconsulters but missed significantly more school and their mothers reported more fears about RAP. Severity of symptoms and psychological distress did not predict consulting behavior. Only maternal fears about abdominal symptoms differentiated consulters from nonconsulters.

Abdominal Pain↗

PubMed1999

Antiviral properties of a mangrove plant, Rhizophora apiculata Blume, against human immunodeficiency virus.

A polysaccharide extracted from the leaf of Rhizophora apiculata (RAP) was assessed in cell culture systems, for its activity against human and simian immunodeficiency viruses. RAP inhibited HIV-1 or HIV-2 or SIV strains in various cell cultures and assay systems. It blocked the expression of HIV-1 antigen in MT-4 cells and abolished the production of HIV-1 p24 antigen in peripheral blood mononuclear cells (PBMC); the 50% effective concentration (EC50) of RAP in HIV-1 infected MT-4 cells and in PBMC was 10.7 and 25.9 microg/ml, respectively. RAP (100 microg/ml) completely blocked the binding of HIV-1 virions to MT-4 cells. RAP also reduced the production of viral mRNA when added before virus adsorption. RAP inhibited syncytium formation in cocultures of MOLT-4 cells and MOLT-4/HIV-1(IIIB) cells. RAP did not prolong activated partial thromboplastin time (APTT) up to 500 microg/ml. These properties may be advantageous should RAP be considered for further development.

Anti-HIV Agents↗

PubMed2002

Receptor-associated protein facilitates proper folding and maturation of the low-density lipoprotein receptor and its class 2 mutants.

Familial hypercholesterolemia is the consequence of various mutations in the low-density lipoprotein receptor (LDLR). In the current study, we show that a specialized molecular chaperone, the receptor-associated protein (RAP), promotes proper folding and subsequent exocytic trafficking of the wild-type LDLR and several of its class 2 mutants. Co-immunoprecipitation with anti-RAP antibody demonstrates that RAP interacts with the LDLR. Kinetic analyses of LDLR posttranslational folding and maturation in the absence or presence of RAP coexpression show that RAP prevents aggregation and promotes the maturation of the LDLR. Additionally, depletion of Ca(2+) in intact cells impairs LDLR folding, and coexpression of RAP partially corrects this misfolding. Finally, we show that the increased mature cell surface LDLR in the presence of RAP coexpression is functional in its ability to endocytose and degrade (125)I-LDL. Taken together, our results show that the folding, trafficking, and maturation of the LDLR and its class 2 mutants are promoted by RAP.

Amino Acid Substitution↗

PubMed2004

The role of cholecystectomy in reducing recurrent gallstone pancreatitis.

BACKGROUND AND STUDY AIM: Endoscopic sphincterotomy (ES) or cholecystectomy can prevent recurrent acute pancreatitis (RAP) in patients with gallstone-related pancreatitis. However, it is unknown whether cholecystectomy after ES offers additional benefit in preventing RAP in these patients. This is a retrospective study to assess whether cholecystectomy can decrease the incidence of RAP in patients with gallstone-related pancreatitis. PATIENTS AND METHODS: Records from 139 patients with gallstone-related pancreatitis were analyzed. Of these, 58 patients had gallbladder stones with concomitant common bile duct (CBD) stones and 81 patients had gallbladder stones without CBD stones. Of the 58 patients who had both gallbladder and CBD stones, 37 (63.8 %) did not undergo cholecystectomy after ES (group 1) and 21 patients (36.2 %) did undergo cholecystectomy after ES (group 2). Of the 81 patients who had gallbladder stones but who did not have CBD stones, 54 (66.7 %) did not undergo cholecystectomy (group 3) and 27 (33.3 %) did undergo cholecystectomy (group 4). RESULTS: At the time of analysis, three patients (8.1 %) in group 1 and three patients (14.3 %) in group 2 developed RAP. There was no significant difference in the estimated probability of occurrence of RAP over time between group 1 and group 2 ( P = 0.41). However, there was a significantly higher probability of patients developing RAP over time in group 3 compared with group 4 (6/54 vs. 0/27 respectively, P = 0.04). CONCLUSION: In patients with gallbladder stones without CBD stones, cholecystectomy can decrease the incidence of RAP. In patients with both gallbladder and CBD stones, however, the risk of RAP was not further reduced by cholecystectomy after ES and complete removal of CBD stones.

Aged↗

PubMed2006

[Retinal angiomatous proliferation in age-related macular degeneration].

BACKGROUND: Angiomatous proliferation in ARMD originates from the retina and extends into the subretinal space. Retinal angiomatous proliferation (RAP) is diagnosed with angiography. This study investigates the characteristics of RAP in optical coherence tomography (OCT) and correlates them with clinical and fluorescein angiographic findings. METHODS: 327 consecutive patients with age-related macular degeneration (ARMD) were retrospectively examined using a standardised protocol. The protocol included best corrected visual acuity (BCVA), binocular ophthalmoscopy, fundus photography, fluorescein angiography (FAG) and OCT. The OCT and angiographic findings were graded in 3 RAP stages. RESULTS: 32 of 327 (9.79 %) patients (45 eyes) had RAP. The age ranged from 56 to 90 years (median: 79 years). 9 eyes presented RAP stage I, 23 stage II and 13 stage III. BCVA ranged from 0.01 to 0.7 (median: 0.2). OCT foveal minimum was 136 to 722 microns (median: 327). 33 (73 %) eyes showed a detachment of retinal pigment epithelium (RPE). Macular oedema was found in 43 (96 %) eyes. Cystoid macular oedema was seen in 36 (80 %) eyes. In stage II, 22 eyes (96 %) showed an RPE detachment, in stage III 11 eyes (85 %). 11 (85 %) eyes in stage III showed retinal-choroidal anastomosis. CONCLUSIONS: RAP was found in 9.79 % of the patients with ARMD. The OCT is helpful in detection of RPE detachment, macular oedema and cystoid changes in RAP. RAP and retinal-choroidal anastomosis should be identified because of the possibly poor prognosis.

Aged↗

PubMed1986

Atrial natriuretic factor stimulates Na/K/Cl cotransport in vascular smooth muscle cells.

Atrial natriuretic factor (ANF) is a collective term used to describe a group of peptides isolated from mammalian atria which have vasorelaxant activity as well as diuretic and natriuretic activity. Recently, ANF peptides have been shown to bind to specific receptors on vascular smooth muscle cells (VSMC) and to cause an elevation in cGMP levels. We have previously demonstrated that VSMC possess a prominent, cyclic-nucleotide-sensitive Na/K/Cl cotransport system. In the present study, the effects of the ANF peptide rat atriopeptin III (rAP III) were measured on Na/K/Cl cotransport of VSMC by using primary cultures derived from rat thoracic aorta. It was found that rAP III caused a marked elevation of Na/K/Cl cotransport. Maximal stimulation occurred at 100 nM, and the dose of rAP III required for half-maximal potassium influx (K1/2) was 9 nM. We also investigated the effect of rAP III on cGMP levels in VSMC. It was found that rAP III increased cGMP in a dose-dependent manner, with a K1/2 value of 10 nM. Finally, we measured the effect of the permeable cGMP analog 8-bromo-cGMP on Na/K/Cl cotransport. It was found that 8-bromo-cGMP stimulated cotransport to the same extent as did a saturating dose of rAP III (K1/2 = 0.2 microM). Saturating doses of rAP III and 8-Br-cGMP in combination did not stimulate cotransport in an additive manner, suggesting that rAP III probably does not elevate cGMP via inhibition of phosphodiesterase. These findings suggest that activation of Na/K/Cl cotransport via elevations in cGMP may be associated with ANF-mediated vasorelaxation and/or ANF-mediated diuresis and natriuresis.

Animals↗

PubMed1998

Regulation of the mouse cartilage-derived retinoic acid-sensitive protein gene by the transcription factor AP-2.

The expression of cartilage-derived retinoic acid-sensitive protein (CD-RAP) is initiated at the beginning of chondrogenesis and continues throughout the cartilage development. In chondrocytes, CD-RAP is down-regulated by retinoic acid. To understand the molecular mechanism underlying this regulation and the cell-specific expression, the deletion constructs of the mouse CD-RAP promoter were transfected into chondrocytes and a melanoma cell line. The results revealed a domain that demonstrated high levels of expression specifically in chondrocytes. In this functional domain, we show that a cis-acting element, 5'-GCCTGAGGC-3', binds to the trans-acting factor protein AP-2. Mutation of the AP-2 site on the CD-RAP promoter led to decreased transcription in C5.18 chondrocytes, indicating that this site may act as an activator of transcription. In contrast, increased concentration of AP-2, stimulated by retinoic acid, led to decreased transcription of the CD-RAP promoter, an effect that was abolished by mutation of the AP-2 binding site. The effect of AP-2 was further examined by co-transfection of C5.18 and HepG2 cells with the CD-RAP promoter constructs and an AP-2 expression plasmid. In a dose-dependent manner, cotransfection with AP-2 elevated and then decreased CD-RAP promoter activity. Taken together, these results suggest that AP-2 is involved in the biphasic regulation of CD-RAP transcription.

Animals↗

PubMed2003

Human leukocyte-derived arginine aminopeptidase. The third member of the oxytocinase subfamily of aminopeptidases.

In this study we report the cloning and characterization of a novel human aminopeptidase, which we designate leukocyte-derived arginine aminopeptidase (L-RAP). The sequence encodes a 960-amino acid protein with significant homology to placental leucine aminopeptidase and adipocyte-derived leucine aminopeptidase. The predicted L-RAP contains the HEXXH(X)18E zinc-binding motif, which is characteristic of the M1 family of zinc metallopeptidases. Phylogenetic analysis indicates that L-RAP forms a distinct subfamily with placental leucine aminopeptidase and adipocyte-derived leucine aminopeptidase in the M1 family. Immunocytochemical analysis indicates that L-RAP is located in the lumenal side of the endoplasmic reticulum. Among various synthetic substrates tested, L-RAP revealed a preference for arginine, establishing that the enzyme is a novel arginine aminopeptidase with restricted substrate specificity. In addition to natural hormones such as angiotensin III and kallidin, L-RAP cleaved various N-terminal extended precursors to major histocompatibility complex class I-presented antigenic peptides. Like other proteins involved in antigen presentation, L-RAP is induced by interferon-gamma. These results indicate that L-RAP is a novel aminopeptidase that can trim the N-terminal extended precursors to antigenic peptides in the endoplasmic reticulum.

Amino Acid Sequence↗

PubMed1998

Non-stoichiometric reduced complexity probes for cDNA arrays.

A method is presented in which the reduced complexity and non-stoichiometric amplification intrinsic to RNA arbitrarily primed PCR fingerprinting (RAP-PCR) is used to advantage to generate probes for differential screening of cDNA arrays. RAP-PCR fingerprints were converted to probes for human cDNA clones arrayed as Escherichia coli colonies on nylon membranes. Each array contained 18 432 cDNA clones from the IMAGE consortium. Hybridization to approximately 1000 cDNA clones was detected using each RAP-PCR probe. Different RAP-PCR fingerprints gave hybridization patterns having very little overlap (<3%) with each other or with hybridization patterns from total cDNA probes. Consequently, repeated application of RAP-PCR probes allows a greater fraction of the message population to be screened on this type of array than can be achieved with a radiolabeled total cDNA probe. This method was applied to RNA from HaCaT keratinocytes treated with epidermal growth factor. Two RAP-PCR probes detected hybridization to 2000 clones, from which 22 candidate differentially expressed genes were observed. Differential expression was tested for 15 of these clones using RT-PCR and 13 were confirmed. The use of this cDNA array to analyze RAP-PCR fingerprints allowed for an increase in detection of 10-20-fold over the conventional denaturing polyacrylamide gel approach to RAP-PCR or differential display. Throughput is vastly improved by the reduction in cloning and sequencing afforded by the use of arrays. Also, repeated cloning and sequencing of the same gene or of genes already known to be regulated in the system of interest is minimized. The procedure we describe uses inexpensive arrays of plasmid clones spotted as E.coli colonies to detect differential expression, but these reduced complexity probes should also prove useful on arrays of PCR-amplified fragments and on oligonucleotide chips. Genesobserved in this manuscript: H11520, U35048, R48633, H28735, M13918, H12999, H05639, X79781, M31627, H23972, AB000712, R75916, U66894, AF067817.

DNA, Complementary↗

PubMed1999

The influence of HLA-DRB1 alleles encoding the DERAA amino acid motif on radiological outcome in rheumatoid arthritis.

OBJECTIVES: To investigate the influence of HLA-DRB1 alleles encoding the QK/RRAA shared epitope (SE) on radiological outcome in rheumatoid arthritis (RA), and to determine whether it is modulated by alleles carrying the putative rheumatoid arthritis-protective (RAP) sequence DERAA. Patients and methods. The association between erosive damage and HLA-DRB1 status was examined in 315 RA patients with a disease duration of 5-30 yr. Radiological outcome was measured by scoring X-rays of the hands and feet using the standard radiographs of Larsen (Larsen score). HLA-DRB1 typing was carried out using polymerase chain reaction methodology. RESULTS: Patients with two alleles encoding the QK/RRAA SE had significantly higher Larsen scores than SE-negative patients (96.9 vs 83.3; P=0.04, after correction for multiple testing), with DRB1*0401/*0401 homozygotes demonstrating the greatest radiological damage (99.9). The lowest Larsen score (65.6) was observed in patients carrying the DERAA motif without an accompanying SE allele (RAP+/SE-). This was significantly lower than in patients with RAP+/SE+ (105.6; P=0.04), RAP-/SE- (88.2; P=0.05) and RAP-/SE+ (95.8; P=0.009), after correction for multiple testing. There was no evidence that the RAP sequence was modulating the effect of the SE since radiological outcome in RAP+/SE+ patients was not significantly different to that in RAP-/SE+ individuals. CONCLUSIONS: Our data support a possible role for DRB1 alleles encoding the DERAA motif in protection against severe erosive damage in patients lacking the QK/RRAA SE, but not in patients heterozygous for the SE. This suggests that DRB1 alleles encoding the SE have a dominant influence over 'protective alleles' and are not merely 'non-protective'.

Alleles↗

PubMed1988

PEEP does not affect left atrial-right atrial pressure difference in neurosurgical patients.

Positive end-expiratory pressure (PEEP) has been used to prevent and treat venous air embolism in patients in the seated position undergoing neurosurgical operations. However, the safety of PEEP has recently been questioned, because of concern that PEEP might increase right atrial pressure (RAP) more than left atrial pressure, thereby predisposing patients with a probe-patent foramen ovale to paradoxical air embolism. In a prior study in dogs, the authors found that to up 10 cm H2O PEEP did not affect the interatrial pressure difference. In the present study, the authors examined the effects of 0, 5, and 10 cm H2O PEEP in 12 anesthetized neurosurgical patients positioned both supine and seated prior to operation. Measurements were made of systemic arterial pressure, RAP, mean pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PAWP), and cardiac output. PAWP was higher (average 2 mmHg) than RAP in all patients. PEEP increased RAP and PAWP in patients, both seated and supine (mean 3 mmHg at 10 cm H2O), but did not affect the PAWP-RAP difference. In an additional eight patients in the seated position, the authors examined the effects of 0, 10, and 20 cm H2O PEEP during operation. PEEP again increased PAWP and RAP, but did not significantly affect the PAWP-RAP difference. The PAWP-RAP difference became negative (-1 mmHg) in one patient with 20 cm H2O PEEP. The authors conclude that levels of PEEP up to 10 cm H2O do not alter the interatrial pressure difference in seated neurosurgical patients, and, therefore, would not predispose these patients to paradoxical air embolism.

Adult↗

PubMed2000

Right atrial pressure predicts hemodynamic response to apneic positive airway pressure.

OBJECTIVE: To evaluate if the preexistant filling state, assessed by right atrial pressure (RAP), pulmonary artery occlusion pressure (PAOP), and right ventricular end-diastolic volume index (EDVI), would define the subsequent hemodynamic effects of increases in airway pressure (Paw). DESIGN: Prospective open clinical study. SETTING: Postoperative intensive care unit, university hospital. PATIENTS: Twenty-two consecutive ventilator-dependent patients with mild to severe acute lung injury with Murray scores (scoring infiltrates on chest radiograph, oxygenation index, lung compliance, and the level of positive end-expiratory pressure) ranging from 0.5 to 3.0 without history of preexisting cardiopulmonary disease. INTERVENTIONS: Paw varied during apnea from 0 to 10, 20, and 30 cm H2O using inspiratory hold maneuvers of 15 secs. MEASUREMENTS AND MAIN RESULTS: Cardiac index and right ventricular ejection fraction were measured by the thermodilution technique. We made measurements in triplicate using manual injection of iced saline. Right ventricular volumes were calculated. Increasing Paw induced variable changes in cardiac index among subjects (+6% to -43% change from baseline 0 cm H2O Paw values), which correlated with percentage changes in both stroke index (r2 = .89) and right ventricular EDVI (r2 = .75), whereas heart rate and right ventricular ejection fraction did not change. The change in cardiac index from 0 to 30 cm H2O Paw correlated with baseline values for RAP, PAOP, and right ventricular EDVI (r2 = .68, .43, and .34, respectively, p < 0.01). Increases in RAP correlated with lung compliance if baseline RAP was >10 mm Hg but did not if it was < or =10 mm Hg. Similarly, patients with baseline RAP < or =10 mm Hg had a greater decrease in cardiac index than patients with a RAP >10 mm Hg (for 30 cm H2O Paw: -30% +/- 9% vs. -8% +/- 7%, p < .01). CONCLUSIONS: Apneic positive Paw decreased cardiac output mainly by reducing venous return. From the investigated filling variables, RAP was most sensitive in predicting the hemodynamic response, followed by PAOP and right ventricular EDVI. Patients with RAP < or =10 mm Hg, if subjected to aggressive positive pressure ventilation, are at risk of hemodynamic deterioration and organ hypoperfusion.

Adult↗