XXXVIII COMU Scientific Awards

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Comparison between amiodarone and lidocaine for ventricular fibrillation treatment during cardiopulmonary resuscitation: a systematic review

Cardiac arrest is a condition in which the heart mechanical functioning is compromised and usually it is due an electrical dysfunction of the cardiac cells and this can result in disorganization of cardiac rhythm and even heart failure, a situation of medical emergency in which seconds can make the difference between life and death. In cardiac arrest, it’s necessary to perform cardiopulmonary resuscitation (CPR) maneuver and, if there are shockable rhythms (such as ventricular fibrillation and pulseless ventricular tachycardia), defibrillation should be administered on the patient. Even if the cardiac rhythm is reestablished, the condition is still serious due to the risk of recurrent electrical alteration of the heart. With the intent of avoiding a new rhythmic alteration of the heart, it’s ministered antiarrhythmic drugs, such as amiodarone or lidocaine. Eventhough the use of one of these drugs is recommended, there are no consensuses about which one has higher survival rate of patients or which has the highest rate of return of spontaneous circulation. Thus, this systematic review aims to clarify which one of these two drugs is more efficient at preventing new electrical alterations of patients post cardiorespiratory arrest.A parada cardíaca é uma condição em que o funcionamento mecânico do coração é comprometido e usualmente é devida a uma disfunção elétrica das células cardíacas, que pode resultar na desorganização do ritmo cardíaco, até numa falência cardíaca, uma situação de emergência médica em que segundos podem fazer a diferença entre a vida e a morte. Na parada cardíaca, é necessário que se realizem manobras de reanimação cardiopulmonar (RCP) e, caso haja presença de ritmo chocável (como a fibrilação ventricular e taquicardia ventricular sem pulso), se administre a desfibrilação no paciente. Mesmo que o ritmo cardíaco seja restabelecido, a condição ainda é grave devido ao risco de retorno da alteração elétrica do coração. Com a intenção de evitar novas alterações rítmicas do coração, são administradas drogas antiarrítmicas, como amiodarona e lidocaína. Embora seja recomendado o uso de um desses fármacos, não há consenso sobre qual deles tem maior sobrevida de pacientes, ou qual tem maior taxa de retorno de circulação espontânea. Sendo assim, essa revisão sistemática busca elucidar qual dessas duas drogas é mais eficiente para evitar novas alterações elétricas em pacientes pós-parada cardiorrespiratória

Comunicação e cuidados paliativos em demência: revisão de 5 anos

Demência é uma condição de prevalência crescente na população mundial, de grande correlação com o envelhecimento. Nós revisamos artigos sobre comunicação e cuidados paliativos em pacientes com demência, seus familiares e cuidadores publicados nos últimos 5 anos. Objetivamos sintetizar as principais estratégias de comunicação nessa população específica, de modo a entender melhor seus desejos e necessidades.Dementia is a increasingly prevalent disease in the world’s population. We reviewed the last 5-years articles in communication and palliative care in patients with dementia, their families and their caregivers. Our objective was to summarize the main strategies of communication in this specific population, in order to understand their desires and need

Effects of diazoxide in experimental acute necrotizing pancreatitis

OBJECTIVE: We aimed to assess the effects of diazoxide on the mortality, pancreatic injury, and inflammatory response in an experimental model of acute pancreatitis. METHODS: Male Wistar rats (200-400 g) were divided randomly into two groups. Fifteen minutes before surgery, animals received physiological (0.9%) saline (3 mL/kg) (control group) or 45 mg/kg diazoxide (treatment group) via the intravenous route. Acute pancreatitis was induced by injection of 2.5% sodium taurocholate via the biliopancreatic duct. Mortality (n=38) was observed for 72 h and analyzed by the Mantel-Cox Log-rank test. To study pancreatic lesions and systemic inflammation, rats (10 from each group) were killed 3 h after acute pancreatitis induction; ascites volume was measured and blood as well as pancreases were collected. Pancreatic injury was assessed according to Schmidt’s scale. Cytokine expression in plasma was evaluated by the multiplex method. RESULTS: Mortality at 72 h was 33% in the control group and 60% in the treatment group (p=0.07). Ascites volumes and plasma levels of cytokines between groups were similar. No difference was observed in edema or infiltration of inflammatory cells in pancreatic tissues from either group. However, necrosis of acinar cells was lower in the treatment group compared to the control group (3.5 vs. 3.75, p=0.015). CONCLUSIONS: Treatment with diazoxide can reduce necrosis of acinar cells in an experimental model of acute pancreatitis, but does not affect the inflammatory response or mortality after 72 h

Effects of mindfulness and meditation techniques on mental health of Emergency Department healthcare workers: a systematic review

Contexto: Profissionais de saúde que atuam no Departamento de Emergência (DE) estão sob risco de estresse e burnout. Meditação e mindfulness são alternativas propostas para redução da frequência e intensidade desses desfechos. Objetivos: Avaliar se meditação e mindfulness reduzem a frequência de desfechos negativos de saúde mental em profissionais no DE. Métodos: Foram analisados artigos em Inglês que estudaram intervenções utilizando técnicas de meditação e desfechos em saúde mental de profissionais do DE. PubMed, SciELO e LILACS foram utilizadas como bases de dados. Resultados: Foram incluídos 8 estudos, que avaliaram diferentes técnicas de meditação e desfechos heterogêneos. A intervenção foi associada a redução de burnout, exaustão emocional ou aumento na satisfação no trabalho. Discussão: Achados indicam que meditação e mindfulness reduzem desfechos negativos de saúde mental. Alguns estudos têm problemas e limitações, como pequeno tamanho amostral. Além disso, as medidas dos desfechos foram heterogêneas, e seus resultados não são de todo concordantes. Ensaios clínicos com maior número de participantes são necessários para tirar conclusões com relação à efetividade dessas intervenções.Background: Working in the Emergency Department (ED) is linked to mental health effects, such as stress and burnout. Meditation and mindfulness are seen as ways of reducing the frequency and intensity of these issues. Objectives: To evaluate if meditation and mindfulness reduce the frequency of negative mental health outcomes among ED Healthcare Workers. Methods: We included studies in English which analyzed interventions using meditation or mindfulness and ED staff’s mental health outcomes. PubMed, SciELO and LILACS were used as databases. Results: 8 studies were included. Meditation techniques and outcomes evaluated were heterogeneous. Interventions were associated with reduced burnout, emotional exhaustion, or increased job satisfaction. Discussion: This study indicates that meditation and mindfulness decrease frequency and intensity of negative mental health outcomes among professionals in the ED. This review has limitations: some studies have methodological problems and limitations such as small sample size; measurements of outcomes were heterogeneous, and results are not always concordant. Studies with higher sample sizes and stricter methodology are needed for us to achieve conclusions about the effectiveness of these interventions

Hypertonic saline and reduced peroxynitrite formation in experimental pancreatitis

OBJECTIVES: In this study, we tested the hypothesis that hypertonic saline exerts anti-inflammatory effects by modulating hepatic oxidative stress in pancreatitis. INTRODUCTION: The incidence of hepatic injury is related to severe pancreatitis, and hypertonic saline reduces pancreatic injury and mortality in pancreatitis. METHODS: Wistar rats were divided into four groups: control (not subjected to treatment), untreated pancreatitis (NT, pancreatitis induced by a retrograde transduodenal infusion of 2.5% sodium taurocholate into the pancreatic duct with no further treatment administered), pancreatitis with normal saline (NS, pancreatitis induced as described above and followed by resuscitation with 0.9% NaCl), and pancreatitis with hypertonic saline (HS, pancreatitis induced as described above and followed by resuscitation with 7.5% NaCl). At 4, 12, and 24 h after pancreatitis induction, liver levels of inducible nitric oxide synthase (iNOS), heat-shock protein 70, nitrotyrosine (formation of peroxynitrite), nitrite/nitrate production, lipid peroxidation, and alanine aminotransferase (ALT) release were determined. RESULTS: Twelve hours after pancreatitis induction, animals in the HS group presented significantly lower iNOS expression (P<0.01 vs. NS), nitrite/nitrate levels (P<0.01 vs. NS), lipid peroxidation (P<0.05 vs. NT), and ALT release (P<0.01 vs. NS). Twenty-four hours after pancreatitis induction, nitrotyrosine expression was significantly lower in the HS group than in the NS group (P<0.05). DISCUSSION: The protective effect of hypertonic saline was related to the establishment of a superoxide-NO balance that was unfavorable to nitrotyrosine formation. CONCLUSIONS: Hypertonic saline decreases hepatic oxidative stress and thereby minimizes liver damage in pancreatitis

Low-level laser therapy (808 nm) contributes to muscle regeneration and prevents fibrosis in rat tibialis anterior muscle after cryolesion

Muscle regeneration is a complex phenomenon, involving replacement of damaged fibers by new muscle fibers. During this process, there is a tendency to form scar tissue or fibrosis by deposition of collagen that could be detrimental to muscle function. New therapies that could regulate fibrosis and favor muscle regeneration would be important for physical therapy. Low-level laser therapy (LLLT) has been studied for clinical treatment of skeletal muscle injuries and disorders, even though the molecular and cellular mechanisms have not yet been clarified. The aim of this study was to evaluate the effects of LLLT on molecular markers involved in muscle fibrosis and regeneration after cryolesion of the tibialis anterior (TA) muscle in rats. Sixty Wistar rats were randomly divided into three groups: control, injured TA muscle without LLLT, injured TA muscle treated with LLLT. The injured region was irradiated daily for four consecutive days, starting immediately after the lesion using an AlGaAs laser (808 nm, 30 mW, 180 J/cm[superscript 2]; 3.8 W/cm[superscript 2], 1.4 J). The animals were sacrificed on the fourth day after injury. LLLT significantly reduced the lesion percentage area in the injured muscle (p < 0.05), increased mRNA levels of the transcription factors MyoD and myogenin (p < 0.01) and the pro-angiogenic vascular endothelial growth factor (p < 0.01). Moreover, LLLT decreased the expression of the profibrotic transforming growth factor TGF-β mRNA (p < 0.01) and reduced type I collagen deposition (p < 0.01). These results suggest that LLLT could be an effective therapeutic approach for promoting skeletal muscle regeneration while preventing tissue fibrosis after muscle injury.National Institutes of Health (U.S.) (grant R01AI050875)Coordenação de Aperfeiçoamento de Pessoal de Nível SuperiorConselho Nacional de Pesquisas (Brazil)Fundação de Amparo à Pesquisa do Estado de São Paul

Reduction of venous pressure during the resection of liver metastases compromises enteric blood flow: IGFBP-1 as a novel biomarker of intestinal barrier injury

OBJECTIVES: Disruption of the intestinal barrier and bacterial translocation commonly occur when intestinal blood flow is compromised. The aim of this study was to determine whether liver resection induces intestinal damage. METHODS: We investigated intestinal fatty-acid binding protein and insulin-like growth factor binding protein levels in the plasma of patients who underwent liver resection. RESULTS: We show that liver resection is associated with significant intestinal barrier injury, even if the Pringle maneuver is not performed. CONCLUSION: We propose the use of insulin-like growth factor binding protein-1 as a novel biomarker of intestinal damage in such situations

Efetividade do serviço móvel de urgência (Samu): uso de séries temporais interrompidas

OBJETIVO: Avaliar o desempenho do serviço de atendimento móvel de urgência (Samu) na região do Grande ABC, utilizando como condição traçadora o infarto agudo do miocárdio. MÉTODOS: A análise de séries temporais interrompidas foi a abordagem de escolha para testar efeitos imediatos e graduais da intervenção na população de estudo. A pesquisa compreendeu séries temporais mensais ajustadas da taxa de mortalidade hospitalar por infarto agudo do miocárdio no período entre 2000 e 2011. Os dados foram extraídos do Sistema de Informações sobre Mortalidade, usando a análise de regressão segmentada para avaliar o nível e tendência da intervenção antes e após sua implementação. Para fortalecer a validade interna do estudo, foi incluída uma região controle. RESULTADOS: A análise de séries temporais interrompidas mostrou redução de 0,04 mortes por 100.000 habitantes na taxa de mortalidade em relação à tendência subjacente desde a implantação do serviço de atendimento médico de urgência (p = 0,0040; IC95% -0,0816 – -0,0162) e uma redução no nível de 2,89 mortes por 100.000 habitantes (p = 0,0001; IC95% -4,3293 – -1,4623), ambos com significância estatística. Em relação à região controle, a Baixada Santista, a diferença da tendência do resultado entre desfecho de intervenção e controle pós-intervenção de -0,0639 mortes por 100.000 habitantes mostrou-se estatisticamente significativa (p = 0,0031; IC95% -0,1060 – -0,0219). Não podemos excluir confundimentos, mas limitamos sua presença no estudo incluindo séries de região controle. CONCLUSÕES: Embora a análise de séries temporais interrompidas tenha limitações, essa modelagem pode ser útil para a análise de desempenho de políticas e programas. Apesar de a intervenção estudada não ser uma condição que por si só implica na efetividade, a efetividade não estaria presente sem essa intervenção, que, integrada a outras condições, gera um resultado positivo. O Samu é uma estratégia cuja expansão precisa ser levada em consideração ao formular e consolidar políticas com foco nas urgências e emergências.OBJECTIVE: To evaluate the performance of the Mobile Emergency Medical Services (SAMU) in the ABC Region, using myocardial infarction as tracer condition. METHODS: The analysis of interrupted time series was the approach chosen to test immediate and gradual effects of the intervention on the study population. The research comprised adjusted monthly time series of the hospital mortality rate by myocardial infarction in the period between 2000 and 2011. Data were extracted from the Mortality Information System (SIM), using segmented regression analysis to evaluate the level and trend of the intervention before and after its implementation. To strengthen the internal validity of the study, a control region was included. RESULTS: The analysis of interrupted time series showed a reduction of 0.04 deaths per 100,000 inhabitants in the mortality rate compared to the underlying trend since the implementation of the Emergency Medical Services (p = 0.0040; 95%CI: −0.0816 – −0.0162) and a reduction in the level of 2.89 deaths per 100,000 inhabitants (p = 0.0001; 95%CI: −4.3293 – −1.4623), both with statistical significance. Regarding the control region, Baixada Santista, the difference in the result trend between intervention outcome and post-intervention control of −0.0639 deaths per 100,000 inhabitants was statistically significant (p = 0.0031; 95%CI: −0.1060 – −0.0219). We cannot exclude confounders, but we limited their presence in the study by including control region series. CONCLUSIONS: Although the analysis of interrupted time series has limitations, this modeling can be useful for analyzing the performance of policies and programs. Even though the intervention studied is not a condition that in itself implies effectiveness, the latter would not be present without the former, which, integrated with other conditions, generates a positive result. SAMU is a strategy that must be expanded when formulating and consolidating policies focusing on emergency care