Financial University

OBJECTIVE: It has been shown in a two-center study that high positive end-expiratory pressure (PEEP) and low tidal volume (LTV) improved outcome in ARDS. However, that study involved patients with underlying diseases unique to the study area, was conducted at only two centers, and enrolled a small number of patients. We similarly hypothesized that a ventilatory strategy based on PEEP above the lower inflection point of the pressure volume curve of the respiratory system (Pflex) set on day 1 with a low tidal volume would result in improved outcome in patients with severe and persistent acute respiratory distress syndrome (ARDS). DESIGN: Randomized, controlled clinical trial. SETTING: Network of eight Spanish multidisciplinary intensive care units (ICUs) under the acronym of ARIES (Acute Respiratory Insufficiency: España Study). PATIENTS: All consecutive patients admitted into participating Spanish ICUs from March 1999 to March 2001 with a diagnosis of ARDS were considered for the study. If 24 hrs after meeting ARDS criteria, the Pao2/Fio2 remained < or =200 mm Hg on standard ventilator settings, patients were randomized into two groups: control and Pflex/LTV. INTERVENTIONS: In the control group, tidal volume was 9-11 mL/kg of predicted body weight (PBW) and PEEP > or =5 cm H2O. In the Pflex/LTV group, tidal volume was 5-8 mL/kg PBW and PEEP was set on day 1 at Pflex + 2 cm H2O. In both groups, Fio2 was set to maintain arterial oxygen saturation >90% and Pao2 70-100 mm Hg, and respiratory rate was adjusted to maintain Paco2 between 35 and 50 mm Hg. MEASUREMENTS AND MAIN RESULTS: The study was stopped early based on an efficacy stopping rule as described in the methods. Of 103 patients who were enrolled (50 control and 53 Pflex), eight patients (five in control, three in Pflex) were excluded from the final evaluation because the random group assignment was not performed in one center according to protocol. Main outcome measures were ICU and hospital mortality, ventilator-free days, and nonpulmonary organ dysfunction. ICU mortality (24 of 45 [53.3%] vs. 16 of 50 [32%], p = .040), hospital mortality (25 of 45 [55.5%] vs. 17 of 50 [34%], p = .041), and ventilator-free days at day 28 (6.02 +/- 7.95 in control and 10.90 +/- 9.45 in Pflex/LTV, p = .008) all favored Pflex/LTV. The mean difference in the number of additional organ failures postrandomization was higher in the control group (p < .001). CONCLUSIONS: A mechanical ventilation strategy with a PEEP level set on day 1 above Pflex and a low tidal volume compared with a strategy with a higher tidal volume and relatively low PEEP has a beneficial impact on outcome in patients with severe and persistent ARDS.

BACKGROUND: It is known that choroidal neovascularization (CNV) in age-related macular degeneration (ARMD) may erode through the retinal pigment epithelium, infiltrate the neurosensory retina, and communicate with the retinal circulation in what has been referred to as a retinal–choroidal anastomosis (RCA). This is extremely common in the end stage of disciform disease. In recent years, the reverse also seems to be possible, as angiomatous proliferation originates from the retina and extends posteriorly into the subretinal space, eventually communicating in some cases with choroidal new vessels. This form of neovascular ARMD, termed retinal angiomatous proliferation (RAP) in this article, can be confused with CNV. PURPOSE: The purpose of this article is 1) to review the clinical and angiographic characteristics of a series of patients with RAP and 2) to propose a theoretical sequence of events that accounts for the neovascularized process. METHODS: In this retrospective clinical and angiographic analysis, 143 eyes with RAP (108 patients) were reviewed and classified based on their vasogenic nature and course. Clinical biomicroscopic examination, fluorescein angiography, and indocyanine green angiography were used to evaluate patients. RESULTS: The results of this series suggest that angiomatous proliferation within the retina is the first manifestation of the vasogenic process in this form of neovascular ARMD. Dilated retinal vessels and pre-, intra-, and subretinal hemorrhages and exudate evolve, surrounding the angiomatous proliferation as the process extends into the deep retina and subretinal space. One or more dilated compensatory retinal vessels perfuse and drain the neovascularization, sometimes forming a retinal–retinal anastomosis. Fluorescein angiography in these patients usually revealed indistinct staining simulating occult CNV. Indocyanine green angiography was useful to make an accurate diagnosis in most cases. It revealed a focal area of intense hyperfluorescence corresponding to the neovascularization ("hot spot") and other characteristic findings. Based on understanding of the nature and progression of the neovascularized process, patients with RAP were classified into three vasogenic stages. Stage I involved proliferation of intraretinal capillaries originating from the deep retinal complex (intraretinal neovascularization [IRN]). Stage II was determined by growth of the retinal vessels into the subretinal space (subretinal neovascularization [SRN]). Stage III occurred when CNV could clearly be determined clinically or angiographically. A vascularized pigment epithelial detachment and RCA were inconsistent features of this stage. CONCLUSIONS: Retinal angiomatous proliferation appears to be a distinct subgroup of neovascular ARMD. It may present in one of three vasogenic stages: IRN, SRN, or CNV. Whereas ICG angiography is helpful in diagnosing RAP and in documenting the stage of the neovascularized process, it is frequently difficult to determine the precise nature and location of the new vessel formation. It is important for clinicians to recognize the vasogenic potential and the associated manifestations of this peculiar form of neovascular ARMD so that a proper diagnosis can be made, and when possible, an appropriate management administered.

BACKGROUND: It is known that choroidal neovascularization (CNV) in age-related macular degeneration (ARMD) may erode through the retinal pigment epithelium, infiltrate the neurosensory retina, and communicate with the retinal circulation in what has been referred to as a retinal-choroidal anastomosis (RCA). This is extremely common in the end stage of disciform disease. In recent years, the reverse also seems to be possible, as angiomatous proliferation originates from the retina and extends posteriorly into the subretinal space, eventually communicating in some cases with choroidal new vessels. This form of neovascular ARMD, termed retinal angiomatous proliferation (RAP) in this article, can be confused with CNV. PURPOSE: The purpose of this article is 1) to review the clinical and angiographic characteristics of a series of patients with RAP and 2) to propose a theoretical sequence of events that accounts for the neovascularized process. METHODS: In this retrospective clinical and angiographic analysis, 143 eyes with RAP (108 patients) were reviewed and classified based on their vasogenic nature and course. Clinical biomicroscopic examination, fluorescein angiography, and indocyanine green angiography were used to evaluate patients. RESULTS: The results of this series suggest that angiomatous proliferation within the retina is the first manifestation of the vasogenic process in this form of neovascular ARMD. Dilated retinal vessels and pre-, intra-, and subretinal hemorrhages and exudate evolve, surrounding the angiomatous proliferation as the process extends into the deep retina and subretinal space. One or more dilated compensatory retinal vessels perfuse and drain the neovascularization, sometimes forming a retinal-retinal anastomosis. Fluorescein angiography in these patients usually revealed indistinct staining simulating occult CNV. Indocyanine green angiography was useful to make an accurate diagnosis in most cases. It revealed a focal area of intense hyperfluorescence corresponding to the neovascularization ("hot spot") and other characteristic findings. Based on understanding of the nature and progression of the neovascularized process, patients with RAP were classified into three vasogenic stages. Stage I involved proliferation of intraretinal capillaries originating from the deep retinal complex (intraretinal neovascularization [IRN]). Stage II was determined by growth of the retinal vessels into the subretinal space (subretinal neovascularization [SRN]). Stage III occurred when CNV could clearly be determined clinically or angiographically. A vascularized pigment epithelial detachment and RCA were inconsistent features of this stage. CONCLUSIONS: Retinal angiomatous proliferation appears to be a distinct subgroup of neovascular ARMD. It may present in one of three vasogenic stages: IRN, SRN, or CNV. Whereas ICG angiography is helpful in diagnosing RAP and in documenting the stage of the neovascularized process, it is frequently difficult to determine the precise nature and location of the new vessel formation. It is important for clinicians to recognize the vasogenic potential and the associated manifestations of this peculiar form of neovascular ARMD so that a proper diagnosis can be made, and when possible, an appropriate management administered.

ABSTRACT: The COVID-19 pandemic has disrupted teaching in a variety of institutions, especially in medical schools. Electronic learning (e-learning) became the core method of teaching the curriculum during the pandemic. After 8 weeks of only online learning, a survey was conducted to investigate perception of this type of learning among medical students.A survey was conducted by distributing an online questionnaire to Polish medical students. Data gathered from the survey were analyzed with routine statistical software.Eight hundred four students answered the questionnaire. According to respondents' answers, the main advantages of online learning were the ability to stay at home (69%), continuous access to online materials (69%), learning at your own pace (64%), and comfortable surroundings (54%). The majority of respondents chose lack of interactions with patients (70%) and technical problems with IT equipment (54%) as the main disadvantages. There was no statistical difference between face-to-face and online learning in terms of opinions on the ability of the learning method to increase knowledge (P = .46). E-learning was considered less effective than face-to-face learning in terms of increasing skills (P < .001) and social competences (P < .001). Students assessed that they were less active during online classes compared to traditional classes (P < .001). E-learning was rated as enjoyable by 73% of respondents.E-learning is a powerful tool for teaching medical students. However, successful implementation of online learning into the curriculum requires a well thought-out strategy and a more active approach.

The climate has changed significantly under the influence of human behavior. And first of all, this is due to the change in the proportionality and concentration of greenhouse gases in the atmosphere (water vapor, carbon dioxide, methane, ozone, PFC (perfluorocarbons). This paper analyzes the dynamics of greenhouse gas emissions. Climate change has many consequences on human health throughout the world, especially in African countries. The growth of greenhouse gas emissions is viewed as a cause of infectious and non-infectious diseases, negative effects on nutrition, water security and other social disruptions. The global average temperature gradually increases, and the atmospheric CO2 concentration has exceeded 400 ppm due to the intensification of greenhouse effect. The method of energy balance was featured to simulate the trends in Greenhouse Gas Emission Forecast in different sectors until 2030. Through sensitivity analysis, we found that the reduction of anthropogenic CO2 emissions from people (cars and households) would deescalate the consequences of the above trends. Emissions are mostly associated with industries, which can be reduced if local Government will want to achieve the Paris Agreement goal.

PURPOSE: To evaluate in a general clinic-based cohort of patients with dry eye disease (DED) the distribution of patients with aqueous-deficient or evaporative subtype of DED. METHODS: Schirmer tests and meibomian gland dysfunction (MGD) (Foulks-Bron scoring) were evaluated in both eyes of 299 normal subjects and DED patients (218 women and 81 men) across 10 sites in the European Union and the United States. Using the more severe measurement of the 2 eyes, subjects were considered to have pure aqueous-deficient dry eye (ADDE) with Schirmer values of <7 mm and MGD grades of ≤5. Patients were classified as purely evaporative dry eye with MGD grades of >5 and Schirmer values of ≥7 mm. Subjects were placed into the mixed (hybrid) category if they exhibited both a low Schirmer value of <7 and evidence of MGD with a grade >5. RESULTS: Of the 224 subjects classified with DED using an objective, composite, disease severity scale, 159 were classified into 1 of 3 categories: 79 were classified with only MGD, whereas only 23 were classified as purely aqueous deficient, and 57 showed evidence of both MGD and aqueous deficiency. Overall, 86% of these qualified DED patients demonstrated signs of MGD. The remaining 65 patients showed evidence of DED through other clinical signs, without overt evidence of MGD or ADDE, possibly because of the inherent variability of these signs. CONCLUSIONS: The proportion of subjects exhibiting signs of evaporative dry eye resulting from MGD far outweighs that of subjects with pure ADDE in a general clinic-based patient cohort.

High myopia is very common and one of the major causes of social blindness, especially in East Asian countries. It is characterized by axial length elongation, and induces various specific complications, including cataract formation, retinal detachment from peripheral retinal tears, myopic foveoschisis, macular hole with or without retinal detachment, peripapillary deformation, dome-shaped macula, choroidal/scleral thinning, myopic choroidal neovascularization, and glaucoma. This article will review these complications and discuss the current concepts relating to these complications and their treatments. CONCLUSION: This information will be helpful for the daily practice of treating myopic eyes.

Along with industrialization and rapid urbanization, environmental remediation is globally a perpetual concept to deliver a sustainable environment. Various organic and inorganic wastes from industries and domestic homes are released into water systems. These wastes carry contaminants with detrimental effects on the environment. Consequently, there is an urgent need for an appropriate wastewater treatment technology for the effective decontamination of our water systems. One promising approach is employing nanoparticles of metal oxides as photocatalysts for the degradation of these water pollutants. Transition metal oxides and their composites exhibit excellent photocatalytic activities and along show favorable characteristics like non-toxicity and stability that also make them useful in a wide range of applications. This study discusses some characteristics of metal oxides and briefly outlined their various applications. It focuses on the metal oxides TiO2, ZnO, WO3, CuO, and Cu2O, which are the most common and recognized to be cost-effective, stable, efficient, and most of all, environmentally friendly for a sustainable approach for environmental remediation. Meanwhile, this study highlights the photocatalytic activities of these metal oxides, recent developments, challenges, and modifications made on these metal oxides to overcome their limitations and maximize their performance in the photodegradation of pollutants.

ABSTRACT We show that measurable managerial characteristics have significant explanatory power for corporate financing decisions. First, managers who believe that their firm is undervalued view external financing as overpriced, especially equity financing. Such overconfident managers use less external finance and, conditional on accessing external capital, issue less equity than their peers. Second, CEOs who grew up during the Great Depression are averse to debt and lean excessively on internal finance. Third, CEOs with military experience pursue more aggressive policies, including heightened leverage. Complementary measures of CEO traits based on press portrayals confirm the results.

Abstract Countries enact environmental regulations to achieve sustainable development and ecological sustainability. However, environmental regulations do not guarantee environmental sustainability unless implemented efficiently. Furthermore, political institutions play a key role in the formulation and management of environmental regulations. This research examines the relationship between democracy, environmental regulations, economic growth, and ecological footprint (EF) in the panel of G7 nations from 1985 to 2017. Second generation econometric techniques are used to analyze the data. The empirical evidence indicates that economic growth enhances EF while democracy and environmental regulations positively contribute to ecological sustainability by reducing EF. The causal outcomes reveal that democracy Granger causes EF and renewable energy indicating that democracy curbs environmental degradation and stimulates the share of renewables. Further, democracy and environmental regulations Granger cause each other. Lastly, the implication of these findings for sustainable development and ecological sustainability are discussed.

Abstract This paper scrutinizes how adaptive learning technologies and artificial intelligence (AI) are transforming today's education by making it personalized, accessible, and efficient as well as leading people to accepting, addressing, and mitigating sustainable development. Recently, education witnessed a remarkable technological surge driven by various advances in technology, which can be demonstrated by the increase of the number of scientific publications on this topic from just 1 in 1990 to 636 in 2023. Ongoing digitalization and technological revolution in education together with the novel approach to respect each student's unique learning style and abilities paved the way for adaptive learning technologies represented by the innovative tools that personalize educational experiences to cater to individual learners. All of that contributes to preparing more educated and informed citizens, drives innovation, and supports economic growth necessary for achieving a sustainable future. Our bibliographic study employs VOSviewer to conduct a bibliometric analysis of a total number of 3518 selected publications using the keywords “adaptive learning” and “AI” (represented by articles, proceeding papers, and book chapters) indexed in the Web of Science (WoS) database from 1990 to 2024. Our results demonstrate that recent technological changes played a key role in transforming adaptive learning, which was rather reinforced by the “digital surge” in education brought about by the COVID‐19 pandemic. Our findings can be useful for further development in the field of adaptive education where they can be employed by the relevant stakeholders and policymakers as well as by the scholars and researchers.

OBJECTIVE: To determine the association between body mass index (BMI) and hospital mortality for critically ill adults. DESIGN: Retrospective cohort study. SETTING: One-hundred six intensive care units (ICUs) in 84 hospitals. PATIENTS: Mechanically ventilated adults (n=1,488) with acute lung injury (ALI) included in the Project IMPACT database between December 1995 and September 2001. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over half of the cohort had a BMI above the normal range. Unadjusted analyses showed that BMI was higher among subjects who survived to hospital discharge vs. those who did not (p<.0001). ICU and hospital mortality rates were lower in higher BMI categories. After risk-adjustment, BMI was independently associated with hospital mortality (p<.0001) when modeled as a continuous variable. The adjusted odds were highest at the lowest BMIs and then declined to a minimum between 35 and 40 kg/m2. Odds increased after the nadir but remained below those seen at low BMIs. With use of a categorical designation, BMI was also independently associated with hospital mortality (p=.0055). The adjusted odds were highest for the underweight BMI group (adjusted odds ratio [OR], 1.94; 95% confidence interval [CI], 1.05-3.60) relative to the normal BMI group. As in the analysis using the continuous BMI variable, the odds of hospital mortality were decreased for the groups with higher BMIs (overweight adjusted OR, 0.72; 95% CI, 0.51-1.02; obese adjusted OR, 0.67; 95% CI, 0.46-0.97; severely obese adjusted OR, 0.78; 95% CI, 0.44-1.38). Differences in the use of heparin prophylaxis mediated some of the protective effect of severe obesity. CONCLUSIONS: BMI was associated with risk-adjusted hospital mortality among mechanically ventilated adults with ALI. Lower BMIs were associated with higher odds of death, whereas overweight and obese BMIs were associated with lower odds.

From mid-March to the end of May 2020, millions of Italians were forced to work from home because of the lockdown provisions imposed by the Italian government to contain the COVID-19 epidemic. As a result, many employees had to suddenly switch to remote work, experiencing both troubles and opportunities. Social isolation from colleagues and the workplace represents a typical aspect of remote work which increased significantly during the social confinement imposed by the government. This study investigates the correlates of social isolation in terms of stress, perceived remote work productivity and remote work satisfaction, proposing the sequential mediation of stress and perceived remote work productivity, and the moderating role of concern about the new coronavirus. An online survey was conducted, and the responses of 265 employees showed the deleterious role of social isolation in stress, which leads to decreased perceived remote work productivity that, in turn, is related to remote work satisfaction. Furthermore, the results suggest that concern about the virus moderates the relationships between social isolation and remote work satisfaction, from one side, and remote work perceived productivity and remote work satisfaction from the other. This latter result suggests that the indirect sequential effect of social isolation on remote work satisfaction is conditional on concern about the virus. Some conclusions are drawn to support managers and HR officers in the choices to better manage employees’ work during the health emergency.

The stronger are the associations between household income and child schooling, the lower is intergenerational social mobility and the less equal is opportunity. This study estimates the associations between household income and children's school success in Vietnam. The estimates indicate that these associations are considerable. For example, the income elasticity of completed grades is five times the median estimate of earlier studies. Moreover, this association is strongest for grades completed per year of school, not for completed grades, on which most of the previous literature has focused. There are some gender differences, the most important being a smaller association between income and grades completed per year of school for boys than for girls. This difference implies that schooling of girls is treated as more of a luxury (less of a necessity) than is schooling of boys. This article also investigates some ways in which policies relate to household incomes. School fees are progressive, but school fees are only about one-third of what households pay directly to schools and are a much smaller proportion of a household's total school-related expenditures. Total household expenditures paid directly to schools increase with household income less proportionately than do school fees alone, so the overall structure of such payments is less progressive than is the structure of school fees. Because school enrollment is positively related to household income, moreover, the structure of school fees is less progressive for the entire population than for the selected subset that has children enrolled in school. Further, the two school quality measures that have the strongest positive association with children's school success are much more available to higher-income households, meaning that higher-income households have greater school expenditures in part because they are obtaining higher-quality schooling and not because charges for the same quality schooling are progressive across income classes.

OBJECTIVES: To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ventilated adults, and to define clinical factors that influence these practices. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Canadian critical care practitioners. MEASUREMENTS AND MAIN RESULTS: A total of 273 of 448 eligible physicians (60%) responded. Respondents were well distributed with regard to age, years of practice, specialist certification, size of intensive care unit and hospital, and location of practice. Twenty-nine percent responded that a protocol/care pathway/guideline for the use of sedatives or analgesics is currently in use in their intensive care unit. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents. Of these, 67% use the Ramsay scale, 10% use the Sedation-Agitation Scale, 9% use the Glasgow Coma Scale, and 8% use the Motor Activity Assessment Scale. Only 3.7% of intensivists use a delirium scoring system in their intensive care units. Only 22% of respondents currently have a protocol for the use of neuromuscular blocking agents in their intensive care unit, and 84% of respondents use peripheral nerve stimulation for monitoring. In patients receiving neuromuscular blocking agents for >24 hrs, 63.7% of respondents discontinue the neuromuscular blocking agent daily. Intensivists working in university-affiliated hospitals are more likely to employ a sedation protocol and scale (p < .0001), as are intensivists working in larger intensive care units (>or=15 beds, p < .01). Intensivists with anesthesiology training (and no formal critical care training) are more likely to use a protocol and sedation scale, and critical care-trained intensivists are more likely to use daily interruption. Younger physicians (<40 yrs) are more likely to practice daily interruption (p = .0092). CONCLUSIONS: There is significant variation in critical care sedation, analgesia, and neuromuscular blockade practice. Given the potential effect of practices regarding these medications on patient outcome, future research and educational efforts related to evidence-based protocols for the use of these agents in mechanically ventilated patients might be worthwhile.

Abstract The high pace of economic growth has posed many challenges. These challenges include depletion of natural resources, globalization challenges, and environmental degradation. The Middle East and North Africa (MENA) economies are rich in mineral resources. Economic globalization has put the MENA countries in the spotlight for the developed world. Despite the status of being a hotspot for mineral resource richness, there is limited research on the effect of natural resources and economic globalization on the environmental degradation of the MENA countries. This paper examines the effects of natural resource abundance and economic globalization on environmental quality by considering trade openness, urbanization, and economic growth from the year 1980 to 2018. We apply second‐generation panel cointegration techniques along with continuously updated fully modified (Cup‐FM) and continuously updated bias‐corrected (Cup‐BC) techniques. The findings show that natural resource abundance significantly improves environmental quality. Likewise, economic globalization also mitigates emissions levels in the MENA countries. In contrast, trade openness, urbanization, and economic growth significantly deteriorate environmental quality. The unidirectional link indicates natural resources and economic globalization create trade openness. The paper provides novel empirical evidence and policy recommendations for sustainable development goals.

ABSTRACT Within the context of takeovers, this paper shows that in private‐value auctions the optimal individually rational strategy for a bidder with partial ownership of the item is to overbid, i.e., to bid more than his valuation. This strategy, however, can lead to i ) an inefficient outcome, and ii ) the winning bidder making a net loss. Further, the overbidding result implies that the presence of a large shareholder increases the bid premium in single‐bidder takeovers at the expense of reducing the probability of the takeover actually occurring.

OBJECTIVE: Pressure inflating the lung during mechanical ventilation is the difference between pressure applied at the airway opening (Pao) and pleural pressure (Ppl). Depending on the chest wall's contribution to respiratory mechanics, a given positive end-expiratory and/or end-inspiratory plateau pressure may be appropriate for one patient but inadequate or potentially injurious for another. Thus, failure to account for chest wall mechanics may affect results in clinical trials of mechanical ventilation strategies in acute respiratory distress syndrome. By measuring esophageal pressure (Pes), we sought to characterize influence of the chest wall on Ppl and transpulmonary pressure (PL) in patients with acute respiratory failure. DESIGN: Prospective observational study. SETTING: Medical and surgical intensive care units at Beth Israel Deaconess Medical Center. PATIENTS: Seventy patients with acute respiratory failure. INTERVENTIONS: Placement of esophageal balloon-catheters. MEASUREMENTS AND MAIN RESULTS: Airway, esophageal, and gastric pressures recorded at end-exhalation and end-inflation Pes averaged 17.5 +/- 5.7 cm H2O at end-expiration and 21.2 +/- 7.7 cm H2O at end-inflation and were not significantly correlated with body mass index or chest wall elastance. Estimated PL was 1.5 +/- 6.3 cm H2O at end-expiration, 21.4 +/- 9.3 cm H2O at end-inflation, and 18.4 +/- 10.2 cm H2O (n = 40) during an end-inspiratory hold (plateau). Although PL at end-expiration was significantly correlated with positive end-expiratory pressure (p < .0001), only 24% of the variance in PL was explained by Pao (R = .243), and 52% was due to variation in Pes. CONCLUSIONS: In patients in acute respiratory failure, elevated esophageal pressures suggest that chest wall mechanical properties often contribute substantially and unpredictably to total respiratory impedance, and therefore Pao may not adequately predict PL or lung distention. Systematic use of esophageal manometry has the potential to improve ventilator management in acute respiratory failure by providing more direct assessment of lung distending pressure.

OBJECTIVE: We tested the hypothesis that hypercapnic acidosis is associated with reduced mortality rate in patients with acute lung injury independent of changes in mechanical ventilation. DESIGN: Secondary analysis of randomized clinical trial data using hypothesis-driven multivariate logistic regression. SETTING: Randomized, multiple-center trial (n = 861) comparing 12 mL/kg to 6 mL/kg predicted body weight tidal volumes previously published by the National Institutes of Health Acute Respiratory Distress Syndrome (ARDS) Network. PATIENTS: Acute lung injury patients enrolled in a randomized, multiple-center trial (n = 861). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The adjusted odds ratio and 95% confidence intervals (CI) for 28-day mortality rate associated with hypercapnic acidosis defined as day 1 pH <7.35 and Pa(CO2) >45 mm Hg were 0.14 (95% CI 0.03-0.70, p = .016) in the 12 mL/kg predicted body weight tidal volume group and 1.18 (95% CI 0.59-2.35, p = .639) in the 6 mL/kg predicted body weight tidal volume group. Other definitions of hypercapnic acidosis spanning a range of magnitudes suggest a dose-response association between hypercapnic acidosis and 28-day mortality in the 12 mL/kg predicted body weight tidal volume group. None of our definitions of hypercapnic acidosis were associated with reduction in 28-day mortality in the 6 mL/kg predicted body weight tidal volume group. CONCLUSIONS: Hypercapnic acidosis was associated with reduced 28-day mortality in the 12 mL/kg predicted body weight tidal volume group after controlling for comorbidities and severity of lung injury. These results are consistent with a protective effect of hypercapnic acidosis against ventilator-associated lung injury that was not found when the further ongoing injury was reduced by 6 mL/kg predicted body weight tidal volumes.

OBJECTIVE: Risk-prediction models offer potential advantages over physician predictions of outcomes in the intensive care unit (ICU). Our systematic review compared the accuracy of ICU physicians' and scoring system predictions of ICU or hospital mortality of critically ill adults. DATA SOURCE: MEDLINE (1966-2005), CINAHL (1982-2005), Ovid Healthstar (1975-2004), EMBASE (1980-2005), SciSearch (1980-2005), PsychLit (1985-2004), the Cochrane Library (Issue 1, 2005), PubMed "related articles," personal files, abstract proceedings, and reference lists. STUDY SELECTION: We considered all studies that compared physician predictions of ICU or hospital survival of critically ill adults to an objective scoring system, computer model, or prediction rule. We excluded studies if they focused exclusively on the development or economic evaluation of a scoring system, computer model, or prediction rule. DATA EXTRACTION AND ANALYSIS: We independently abstracted data and assessed study quality in duplicate. We determined summary receiver operating characteristic curves and areas under the summary receiver operating characteristic curves+/-se and summary diagnostic odds ratios. DATA SYNTHESIS: We included 12 observational studies of moderate methodological quality. The area under the summary receiver operating characteristic curves for seven studies was 0.85+/-0.03 for physician predictions compared with 0.63+/-0.06 for scoring system predictions (p=.002). Physicians' summary diagnostic odds ratios derived from the area under the summary receiver operating characteristic curves were significantly higher (12.43; 95% confidence interval 5.47, 27.11) than scoring systems' summary diagnostic odds ratios (2.25; 95% confidence interval 0.78, 6.52, p=.001). Combined results of all 12 studies indicated that physicians predict mortality more accurately than do scoring systems: ratio of diagnostic odds ratios (95% confidence interval) 1.92 (1.19, 3.08) (p=.007). CONCLUSIONS: Observational studies suggest that ICU physicians discriminate between survivors and nonsurvivors more accurately than do scoring systems in the first 24 hrs of ICU admission. The overall accuracy of both predictions of patient mortality was moderate, implying limited usefulness of outcome prediction in the first 24 hrs for clinical decision making.