Oscillating Positive Expiratory Pressure on Respiratory Resistance in Chronic Obstructive Pulmonary Disease With a Small Amount of Secretion: A Randomized Clinical Trial

Abstract: This study aims to evaluate the acute effects of an oscillating positive expiratory pressure device (flutter) on airways resistance in patients with chronic obstructive pulmonary disease (COPD). Randomized crossover study: 15 COPD outpatients from Asthma Lab–Royal Brompton Hospital underwent spirometry, impulse oscillometry (IOS) for respiratory resistance (R) and reactance (X), and fraction exhaled nitric oxide (FeNO) measures. Thirty minutes of flutter exercises: a “flutter-sham” procedure was used as a control, and airway responses after a short-acting bronchodilator were also assessed. Respiratory system resistance (R): in COPD patients an increase in X5insp (-0.21 to -0.33 kPa/L/s) and Fres (24.95 to 26.16 Hz) occurred immediately after flutter exercises without bronchodilator. Following 20 min of rest, a decrease in the R5, [DELTA]R5, R20, X5, and Ax was observed, with R5, R20, and X5 values lower than baseline, with a moderate effect size; there were no changes in FeNO levels or spirometry. The use of flutter can decrease the respiratory system resistance and reactance and expiratory flow limitation in stable COPD patients with small amounts of secretions

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to 300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m 2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Benefits of postoperative respiratory kinesiotherapy following laparoscopic cholecystectomy

INTRODUÇÃO: Alterações da função pulmonar após cirurgia abdominal levam à redução do volume pulmonar, prejudicando as trocas gasosas. OBJETIVO: Avaliar os efeitos da cinesioterapia respiratória sobre a função pulmonar e a força muscular respiratória em pacientes submetidos à colecistectomia laparoscópica. MATERIAIS E MÉTODOS: Em estudo prospectivo, 20 mulheres e 16 homens (idade: 48,4 &plusmn; 9,55 anos), submetidos à colecistectomia laparoscópica, foram divididos aleatoriamente: 17 realizaram exercícios respiratórios (respiração diafragmática, sustentação máxima da inspiração e inspiração fracionada) e 19 participaram como Grupo Controle. Todos realizaram avaliação das pressões respiratórias máximas (PImax e PEmax), pico de fluxo expiratório (PFE) e espirometria, medindo capacidade vital (CV), capacidade vital forçada (CVF), volume expiratório no primeiro segundo (VEF1), relação VEF1/CVF no pré-operatório e diariamente até o sexto pós-operatório (PO). RESULTADOS: Os valores de pré-operatório não foram estatisticamente diferentes entre os dois grupos. Ambos os grupos apresentaram diminuição de todas as variáveis no 1º PO (p< 0,05). O Grupo Exercício permaneceu com diminuição até o 2º PO para CV, CVF e VEF1 (p< 0,05), 3º PO para PImax e PFE (p< 0,05) e 4º PO para PEmax (p< 0,05), enquanto que, no Grupo Controle, os valores de todas as variáveis retornaram a partir do 5º PO. Os valores de PImax e PEmax foram maiores no Grupo Exercício que no Grupo Controle desde o 3º e 2º PO (p< 0,05), respectivamente. CONCLUSÕES: A cinesioterapia respiratória contribuiu para a recuperação precoce da função pulmonar e da força muscular dos pacientes submetidos à colecistectomia laparoscópica.INTRODUCTION: Pulmonary function changes following abdominal surgery lead to reduced pulmonary volume, thus compromising gas exchanges. OBJECTIVE: To evaluate the effects of respiratory kinesiotherapy on pulmonary function and respiratory muscle strength in patients who underwent laparoscopic cholecystectomy. METHODS: Twenty women and 16 men (age 48.4 &plusmn; 9.55 years) who underwent laparoscopic cholecystectomy were prospectively studied. They were randomly divided as follows: 17 subjects performed breathing exercises (diaphragmatic respiration, maximum sustained inspiration and fractional inspiration) and 19 participated as a Control Group. All of them underwent evaluations of maximal inspiratory and expiratory pressures (MIP and MEP), peak expiratory flow (PEF) and spirometry, with measurements of vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and the FEV1/FVC ratio before the operation and daily until the sixth postoperative day (POD). RESULTS: The preoperative parameters were not statistically different between the two groups. Both groups presented decreases in all variables on the first POD (p< 0.05). The Exercise Group continued to present decreased values until the second POD for VC, FVC, and FEV1 (p< 0.05), until the third POD for MIP and PEF (p< 0.05) and the fourth POD for MEP (p< 0.05). For the Control Group, the values of all the variables began to normalize on the fifth POD. The MIP and MEP values in the Exercise Group were higher than those in the controls, from the third and second POD onwards, respectively. CONCLUSIONS: Respiratory kinesiotherapy contributed towards early recovery of pulmonary function and muscle strength among patients who had undergone laparoscopic cholecystectomy