The Dead Space 3 Italian Dubbed Free Download
Kenneth Calimlim
Objectives: We evaluated a human model of respiratory impairment in 10 COPD-free HF patients and in 10 healthy subjects, tested with a progressive workload exercise with different added dead space. We hypothesized that increased serial dead space upshifts the VE vs. VCO2 relationship and that the VE-axis intercept might be an index of dead space ventilation.
Measurements: All participants performed a cardiopulmonary exercise test with 0, 250 and 500 mL of additional dead space. Since DS does not contribute to gas exchange, ventilation relative to dead space is ventilation at VCO2 = 0, i.e. VE-axis intercept. We compared dead space volume, estimated dividing VE-axis intercept by the intercept on respiratory rate axis of the respiratory rate vs. VCO2 relationship with standard method measured DS.
Physiologic dead space is a well-established independent predictor of death in patients with acute respiratory distress syndrome (ARDS). Here, we explore the association between a surrogate measure of dead space (DS) and early outcomes of mechanically ventilated patients admitted to Intensive Care Unit (ICU) because of COVID-19-associated ARDS. Retrospective cohort study on data derived from Italian ICUs during the first year of the COVID-19 epidemic. A competing risk Cox proportional hazard model was applied to test for the association of DS with two competing outcomes (death or discharge from the ICU) while adjusting for confounders. The final population consisted of 401 patients from seven ICUs. A significant association of DS with both death (HR 1.204; CI 1.019-1.423; p = 0.029) and discharge (HR 0.434; CI 0.414-0.456; p [Formula: see text]) was noticed even when correcting for confounding factors (age, sex, chronic obstructive pulmonary disease, diabetes, PaO[Formula: see text]/FiO[Formula: see text], tidal volume, positive end-expiratory pressure, and systolic blood pressure). These results confirm the important association between DS and death or ICU discharge in mechanically ventilated patients with COVID-19-associated ARDS. Further work is needed to identify the optimal role of DS monitoring in this setting and to understand the physiological mechanisms underlying these associations.
Background: Ventilatory ratio (VR) has been proposed as an alternative approach to estimate physiological dead space. However, the absolute value of VR, at constant dead space, might be affected by venous admixture and CO2 volume expired per minute (VCO2).
Results: A total of 641 mechanically ventilated patients with mild (n=65), moderate (n=363), or severe (n=213) ARDS were studied. Venous admixture was measured (n=153 patients) or estimated using the PaO2/FiO2 ratio (n=448). The VR increased exponentially as a function of the dead space, and the absolute values of this relationship were a function of VCO2. At a physiological dead space of 0.6, VR was 1.1, 1.4, and 1.7 in patients with VCO2 equal to 200, 250, and 300, respectively. VR was independently associated with mortality (odds ratio [OR]=2.5; 95% confidence interval [CI], 1.8-3.5), but was not associated when adjusted for VD/VTphys, VCO2, PaO2/FiO2 (ORadj=1.2; 95% CI, 0.7-2.1). These three variables remained independent predictors of ICU mortality (VD/VTphys [ORadj=17.9; 95% CI, 1.8-185; P
The Judica-Cordiglia brothers are two Italian former amateur radio operators who made audio recordings which allegedly support the conspiracy theory that the Soviet space program covered up cosmonaut deaths in the 1960s.[1] The pair claimed to have recorded several failed secret Soviet space missions. These recordings have been the center of public interest for more than 50 years.[2][3]
In the 1960s, the brothers released recordings alleged to be radio communications taken from secret Soviet Union space missions, including the purported dying sounds of a suffocating lost cosmonaut.[3] As compiled by Kris Hollington of the Fortean Times, a British monthly magazine that popularizes "anomalous phenomena",[citation needed] the quoted list of these is as follows:[2]
The immune-mediated thrombosis of alveolar capillaries may be implicated in the high physiological dead space reported in patients with COVID-19-associated ARDS7,8, which appears unrelated to the compliance of the respiratory system (C\(_\textrmRS\))9.
In a recent secondary analysis of a retrospective national study, the PRoVENT-COVID24, patients with COVID-19-associated ARDS dying within 28 days since the beginning of mechanical ventilation also showed signs of a significantly increased physiologic dead space, both at baseline and in the first 3 days since intubation, as compared to survivors. Interestingly, the trend in physiologic dead space estimations significantly differed over time between survivors and non-survivors, suggesting that dynamic changes in the estimates of dead space during the course of the Intensive Care Unit (ICU) stay may be more informative than single measures at the very beginning of mechanical ventilation.
Here, we hypothesize that the trend of physiologic dead space over time is independently associated with mortality or discharge from the Intensive Care Unit in mechanically ventilated patients with COVID-19-associated ARDS.
The estimator we propose (the dead space estimated according to the modified Bohr equation, based on the EtCO\(_2\)/PaCO\(_2\) ratio), is easy to collect and focuses on physiological quantities directly measured from the patient.
The use of capnography in the ICU and the monitoring of dead space estimates have been long advocated13,25, given their role as a safety measure (assessment of endotracheal tube placement), as a marker of the adequacy of ventilation and global perfusion, and their prognostic role in specific situations, such as ARDS.
Although corrected minute ventilation was found to be significantly associated with in-hospital mortality of patients admitted in the ICU due to COVID-19-induced ARDS17,23, other research focusing on a broader set of dead space estimators24 showed that dead space estimates at the onset and in the first day of mechanical ventilation for COVID-19-associated ARDS were not independent predictors of death at 28 days from the institution of invasive ventilation. However, while dead space estimates were not significantly different between survivors and non-survivors at the beginning and on the first day of mechanical ventilation, significant differences were found in the following days. In our analysis, we found a significant difference in the DS and PaO\(_2\)/FiO\(_2\) ratios between survivors and non-survivors from the first recorded set of physiologic variables, that was maintained through the ICU stay to the last recorded set of variables. Our findings are in line with previous reports who showed an elevated dead space fraction in critically ill patients dying from COVID-19-associated-ARDS9,26, possibly because of a dysregulated endothelial activation promoting pulmonary microthrombosis1,5.
The proposed model and study design do not infer a causal relationship between the variable under study and the competing events, nor try to describe in detail the complex relationships between single ventilatory variables in the context of the altered respiratory physiology of COVID-19-associated ARDS. Rather, our study answers to a broader question about the observed association of the dead space estimation with ICU outcomes, when correcting for relevant confounders derived from comorbidities and major ventilatory and hemodynamic variables.
Our study has several limitations. First, the retrospective nature of the study limits the availability of data for the analysis to those recorded in the electronic health record. Data availability may also depend on local clinical practice as well as current clinical and legal guidelines at the time of collection. Furthermore, the quality of the recorded data in retrospective studies might also be affected, as data have not been collected for research purposes. A second important limitation is that physiologic dead space was estimated using routinely available information in the EHR and not measured with the use of a gold-standard technique such as volumetric capnography. Indeed, blood gas analyses and time capnography have their own limitations, including sample contamination, sample collection mishap, tube positioning and obstruction, among others27,28. A third limitation is that patient status was assumed to be constant within a 1-h window for each set of measurements, thus implying that any delay between measurements belonging to the same time window cannot be considered in profiling the ventilatory and hemodynamic status of the patient.
To our knowledge, this is the first study that directly links time-evolving data with outcomes of critically ill patients with COVID-19-associated ARDS, stressing the importance of dead space monitoring in mechanically ventilated patients, which contains additional information to that provided by the sole monitoring of the PaO\(_2\)/FiO\(_2\) ratio.
The main aim of the study was to investigate the association between physiologic dead space and ICU mortality or ICU discharge within 7 days since the last available measure. Figure 3 graphically depicts the study design.
An ordinary engineer pulled into extraordinary circumstances, Isaac is the sole survivor of the USG Ishimura incident: a mining ship disaster in the far reaches of space that revealed the existence of a monstrous life-after-death infection known as Necromorphs. Isaac's ingenuity and cunning allow him to create improvised tools and weapons from the materials he finds, which may give him the edge he needs to survive in his quest to destroy the Necromorph scourge once and for all.
Isaac and Ellie are searching through space for Tau Volantis. Suddenly, Isaac starts to see visions of a battle between a group of humans and creatures (the other All-Stars). Ellie insists that they put it aside and head for Tau Volantis, knowing that it is the source of the necromorphs, but Isaac senses an even greater power and wants to see for himself. Eventually, she decides to let him investigate.
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