Manejo Agudo do Estado Hiperglicêmico Hiperosmolar: Intervenções de Emergência e Perspectivas

This article aims to analyze current clinical practices in the management of hyperosmolar hyperglycemic state (HHS) in emergency settings. HHS is a severe endocrinological emergency that primarily occurs in patients with uncontrolled type 2 diabetes mellitus, characterized by extreme hyperglycemia, plasma hyperosmolarity, and severe dehydration without significant ketoacidosis. The condition develops insidiously over days or weeks and can lead to severe neurological manifestations such as lethargy, mental confusion, seizures, and coma. It is often triggered by factors such as infections, inadequate medication use, trauma, or concomitant diseases that increase the production of counter-regulatory hormones. The methodology used was a descriptive and qualitative bibliographic review, analyzing studies published between 2004 and 2024, in Portuguese and English. The databases consulted were PubMed, Scielo, and Google Scholar. The analysis focused on the triggering factors of HHS, the effectiveness of emergency interventions, protocols for correcting hyperglycemia and electrolyte disturbances, and the role of endocrinological follow-up in preventing recurrent episodes. The results indicate that proper management of HHS involves aggressive fluid therapy, careful insulin administration, and rigorous monitoring of glycemic and electrolyte levels. Recent advances include the use of continuous glucose monitoring and the application of standardized treatment protocols that significantly improve clinical outcomes. Studies show that implementing such protocols can reduce hospitalization time and mortality associated with HHS. The conclusion highlights the importance of a systematic and evidence-based approach to managing HHS. Early diagnosis and emergency interventions, such as fluid replacement and intensive glycemic control, are essential to stabilize the patient and prevent severe complications such as renal failure and neurological dysfunction. Continued research in this area is crucial to improving treatment strategies, ensuring the safety and efficacy of procedures, and enhancing the quality of life for patients.Este artigo tem como objetivo geral analisar as práticas clínicas atuais no manejo do estado hiperglicêmico hiperosmolar (EHH) em ambientes de emergência. O EHH é uma emergência endocrinológica grave que ocorre principalmente em pacientes com diabetes mellitus tipo 2 não controlada, caracterizada por hiperglicemia extrema, hiperosmolaridade plasmática e desidratação acentuada, sem cetoacidose significativa. A condição desenvolve-se de forma insidiosa ao longo de dias ou semanas e pode levar a manifestações neurológicas graves, como letargia, confusão mental, convulsões e coma. É frequentemente desencadeada por fatores como infecções, uso inadequado de medicamentos, trauma ou doenças concomitantes que aumentam a produção de hormônios contra-reguladores. A metodologia utilizada foi uma revisão bibliográfica descritiva e qualitativa, analisando estudos publicados entre 2004 e 2024, em português e inglês. As bases de dados consultadas foram PubMed, Scielo e Google Scholar. A análise focou nos fatores desencadeantes do EHH, eficácia das intervenções emergenciais, protocolos de correção de hiperglicemia e distúrbios eletrolíticos, e o papel do acompanhamento endocrinológico na prevenção de episódios recorrentes. Os resultados indicam que o manejo adequado do EHH envolve fluidoterapia agressiva, administração criteriosa de insulina e monitoramento rigoroso dos níveis glicêmicos e eletrolíticos. Avanços recentes incluem a utilização de monitoramento contínuo da glicose e a aplicação de protocolos de tratamento padronizados que melhoram significativamente os resultados clínicos. Estudos mostram que a implementação de tais protocolos pode reduzir o tempo de internação e a mortalidade associada ao EHH. A conclusão destaca a importância de uma abordagem sistemática e baseada em evidências no manejo do EHH. O diagnóstico precoce e intervenções emergenciais, como reposição de fluidos e controle glicêmico intensivo, são essenciais para estabilizar o paciente e prevenir complicações severas, como falência renal e disfunção neurológica. A continuidade das pesquisas nesta área é crucial para aprimorar as estratégias de tratamento, garantir a segurança e eficácia dos procedimentos, e melhorar a qualidade de vida dos pacientes

Avanços nas Técnicas de Cirurgia Geral e Plástica para Correção de Fissura Palatina: Uma Revisão Sistemática

This article aims to evaluate advances in surgical techniques for the correction of cleft palate, highlighting the associated benefits and challenges. The specific objectives include identifying and describing the latest techniques, assessing their effectiveness in improving speech, comparing recovery times and complications, studying the success rate in preventing postoperative complications, and examining the need for complementary interventions such as speech therapy. The methodology used was a descriptive and qualitative bibliographic review, analyzing studies published between 2009 and 2024, in Portuguese and English. The databases consulted were PubMed, Scielo, and Google Scholar. The analysis focused on the effectiveness of surgical techniques in improving speech function, reducing recovery times, preventing postoperative complications, and evaluating the need for complementary interventions. The results indicate that recent advances, such as endoscopic surgery and the use of dynamic tension devices, have shown significant benefits, including less tissue trauma, reduced scarring, and better functional and aesthetic outcomes. Additionally, robotic surgery and 3D printing have contributed to personalized surgical planning, resulting in more precise and predictable procedures. Techniques such as Furlow and Bardach present higher success rates in speech correction and prevention of postoperative complications. The conclusion highlights the critical importance of surgical techniques for the correction of cleft palate, evidencing significant advances and associated challenges. Early surgical correction is essential to restore palate integrity, promoting improvements in speech, feeding, hearing, and facial aesthetics. A multidisciplinary approach involving surgeons, speech therapists, orthodontists, and other healthcare professionals is fundamental to ensure the best long-term outcomes for patients with cleft palate. Continued research in this area is crucial to enhance treatment strategies, ensure the safety and efficacy of procedures, and improve patients' quality of life.Este artigo tem como objetivo geral avaliar os avanços nas técnicas cirúrgicas para a correção de fissura palatina, destacando os benefícios e desafios associados. Os objetivos específicos incluem identificar e descrever as técnicas mais recentes, avaliar sua eficácia na melhora da fala, comparar tempos de recuperação e complicações, estudar a taxa de sucesso na prevenção de complicações pós-operatórias e examinar a necessidade de intervenções complementares, como fonoaudiologia. A metodologia utilizada foi uma revisão bibliográfica descritiva e qualitativa, analisando estudos publicados entre 2009 e 2024, em português e inglês. As bases de dados consultadas foram PubMed, Scielo e Google Scholar. A análise focou na eficácia das técnicas cirúrgicas em melhorar a função da fala, reduzir tempos de recuperação, prevenir complicações pós-operatórias e avaliar a necessidade de intervenções complementares. Os resultados indicam que os avanços recentes, como a cirurgia endoscópica e a utilização de dispositivos de tensão dinâmica, têm mostrado benefícios significativos, incluindo menor trauma tecidual, cicatrizes reduzidas e melhores resultados funcionais e estéticos. Além disso, a cirurgia robótica e a impressão 3D têm contribuído para o planejamento cirúrgico personalizado, resultando em procedimentos mais precisos e previsíveis. Técnicas como a de Furlow e a de Bardach apresentam melhores taxas de sucesso na correção da fala e na prevenção de complicações pós-operatórias. A conclusão destaca a importância crítica das técnicas cirúrgicas para a correção da fissura palatina, evidenciando os avanços significativos e os desafios associados. A correção cirúrgica precoce é essencial para restaurar a integridade do palato, promovendo melhorias na fala, alimentação, audição e estética facial. A abordagem multidisciplinar envolvendo cirurgiões, fonoaudiólogos, ortodontistas e outros profissionais de saúde é fundamental para garantir os melhores resultados a longo prazo para pacientes com fissura palatina. A continuidade de pesquisas nesta área é crucial para aprimorar as estratégias de tratamento, garantir a segurança e eficácia dos procedimentos e melhorar a qualidade de vida dos pacientes. &nbsp

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved

Brazilian Flora 2020: Leveraging the power of a collaborative scientific network

International audienceThe shortage of reliable primary taxonomic data limits the description of biological taxa and the understanding of biodiversity patterns and processes, complicating biogeographical, ecological, and evolutionary studies. This deficit creates a significant taxonomic impediment to biodiversity research and conservation planning. The taxonomic impediment and the biodiversity crisis are widely recognized, highlighting the urgent need for reliable taxonomic data. Over the past decade, numerous countries worldwide have devoted considerable effort to Target 1 of the Global Strategy for Plant Conservation (GSPC), which called for the preparation of a working list of all known plant species by 2010 and an online world Flora by 2020. Brazil is a megadiverse country, home to more of the world's known plant species than any other country. Despite that, Flora Brasiliensis, concluded in 1906, was the last comprehensive treatment of the Brazilian flora. The lack of accurate estimates of the number of species of algae, fungi, and plants occurring in Brazil contributes to the prevailing taxonomic impediment and delays progress towards the GSPC targets. Over the past 12 years, a legion of taxonomists motivated to meet Target 1 of the GSPC, worked together to gather and integrate knowledge on the algal, plant, and fungal diversity of Brazil. Overall, a team of about 980 taxonomists joined efforts in a highly collaborative project that used cybertaxonomy to prepare an updated Flora of Brazil, showing the power of scientific collaboration to reach ambitious goals. This paper presents an overview of the Brazilian Flora 2020 and provides taxonomic and spatial updates on the algae, fungi, and plants found in one of the world's most biodiverse countries. We further identify collection gaps and summarize future goals that extend beyond 2020. Our results show that Brazil is home to 46,975 native species of algae, fungi, and plants, of which 19,669 are endemic to the country. The data compiled to date suggests that the Atlantic Rainforest might be the most diverse Brazilian domain for all plant groups except gymnosperms, which are most diverse in the Amazon. However, scientific knowledge of Brazilian diversity is still unequally distributed, with the Atlantic Rainforest and the Cerrado being the most intensively sampled and studied biomes in the country. In times of “scientific reductionism”, with botanical and mycological sciences suffering pervasive depreciation in recent decades, the first online Flora of Brazil 2020 significantly enhanced the quality and quantity of taxonomic data available for algae, fungi, and plants from Brazil. This project also made all the information freely available online, providing a firm foundation for future research and for the management, conservation, and sustainable use of the Brazilian funga and flora

Growing knowledge: an overview of Seed Plant diversity in Brazil

Abstract An updated inventory of Brazilian seed plants is presented and offers important insights into the country's biodiversity. This work started in 2010, with the publication of the Plants and Fungi Catalogue, and has been updated since by more than 430 specialists working online. Brazil is home to 32,086 native Angiosperms and 23 native Gymnosperms, showing an increase of 3% in its species richness in relation to 2010. The Amazon Rainforest is the richest Brazilian biome for Gymnosperms, while the Atlantic Rainforest is the richest one for Angiosperms. There was a considerable increment in the number of species and endemism rates for biomes, except for the Amazon that showed a decrease of 2.5% of recorded endemics. However, well over half of Brazillian seed plant species (57.4%) is endemic to this territory. The proportion of life-forms varies among different biomes: trees are more expressive in the Amazon and Atlantic Rainforest biomes while herbs predominate in the Pampa, and lianas are more expressive in the Amazon, Atlantic Rainforest, and Pantanal. This compilation serves not only to quantify Brazilian biodiversity, but also to highlight areas where there information is lacking and to provide a framework for the challenge faced in conserving Brazil's unique and diverse flora

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research