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To the Editor: Dr Ranieri and colleagues1 demonstrated that among patients affected by acute respiratory distress syndrome (ARDS), those receiving mechanical ventilation with conventional ventilation showed significantly higher levels of pulmonary and systemic mediators compared with patients who received ventilation with a "lung-protective" strategy. The authors concluded that "mechanical ventilation can induce a cytokine response that may be attenuated by a strategy to minimize overdistension and recruitment/derecruitment of the lung." The data suggest that ventilator-induced lung injury also can result in systemic inflammation and associated multiple organ failure.
However, I have several concerns about the study's methods. The authors reported that 7 patients dropped out; these patients were not included in the follow-up. Simply ignoring all patients that withdraw from a clinical trial will bias the results, usually in favor of the intervention. It should be standard practice to analyze the results of clinical trials on an intent-to-treat basis.2 The authors also reported the results in terms of mean (SD), without describing the absolute number of patients with increases in levels of each mediator in each group. It is difficult to extract these numbers from the figures in the article. This way of presenting the results does not allow the reader to compute the risk of outcome event in both groups and it does not describe the clinical impact of the lung-protective strategy in terms of "lungs saved from biotrauma," which remains a surrogate end point.3 Finally, the authors reported only P values and did not provide confidence intervals. Thus, it cannot be established how precise the estimate of the treatment effect was and how likely the results are to be replicable.4
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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