Effect of intravenous beta-2 agonist treatment on clinical outcomes in acute respiratory distress syndrome (BALTI-2): a multicentre, randomised controlled trial

BACKGROUND:
In a previous randomised controlled phase 2 trial, intravenous infusion of salbutamol for up to 7 days in patients with acute respiratory distress syndrome (ARDS) reduced extravascular lung water and plateau airway pressure. We assessed the effects of this intervention on mortality in patients with ARDS.
METHODS:
We did a multicentre, placebo-controlled, parallel-group, randomised trial at 46 UK intensive-care units between December, 2006, and March, 2010. Intubated and mechanically ventilated patients (aged =16 years) within 72 h of ARDS onset were randomly assigned to receive either salbutamol (15 µg/kg ideal bodyweight per h) or placebo for up to 7 days. Randomisation was done by a central telephone or web-based randomisation service with minmisation by centre, pressure of arterial oxygen to fractional inspired oxygen concentration (PaO(2)/F(I)O(2)) ratio, and age. All participants, caregivers, and investigators were masked to group allocation. The primary outcome was death within 28 days of randomisation. Analysis was by intention-to-treat. This trial is registered, ISRCTN38366450 and EudraCT number 2006-002647-86.
FINDINGS:
We randomly assigned 162 patients to the salbutamol group and 164 to the placebo group. One patient in each group withdrew consent. Recruitment was stopped after the second interim analysis because of safety concerns. Salbutamol increased 28-day mortality (55 [34%] of 161 patients died in the salbutamol group vs 38 (23%) of 163 in the placebo group; risk ratio [RR] 1·47, 95% CI 1·03-2·08).
INTERPRETATION:
Treatment with intravenous salbutamol early in the course of ARDS was poorly tolerated. Treatment is unlikely to be beneficial, and could worsen outcomes. Routine use of ß-2 agonist treatment in ventilated patients with this disorder cannot be recommended.

Recent data suggest no further recovery in North Sea Large Fish Indicator

We detail the calculations of North Sea Large Fish Indicator values for 2009-2011, demonstrating an apparent stall in recovery. Therefore, recovery to the Marine Strategy Framework Directive's good environmental status of 0.3 by the 2020 deadline now looks less certain and may take longer than was expected using data from 2006 to 2008.

Quotients, exactness, and nuclearity in the operator system category

We continue our study of tensor products in the operator system category. We define operator system quotients and exactness in this setting and refine the notion of nuclearity by studying operator systems that preserve various pairs of tensor products. One of our main goals is to relate these refinements of nuclearity to the Kirchberg conjecture. In particular, we prove that the Kirchberg conjecture is equivalent to the statement that every operator system that is (min,er)-nuclear is also (el,c)-nuclear. We show that operator system quotients are not always equal to the corresponding operator space quotients and then study exactness of various operator system tensor products for the operator system quotient. We prove that an operator system is exact for the min tensor product if and only if it is (min,el)-nuclear. We give many characterizations of operator systems that are (min,er)-nuclear, (el,c)-nuclear, (min,el)-nuclear and (el,max)-nuclear. These characterizations involve operator system analogues of various properties from the theory of C*-algebras and operator spaces, including the WEP and LLP.