Perioperative hemodynamic goal-directed therapy and mortality: a systematic review and meta-analysis with meta-regression

INTRODUCTION: Recent data found that perioperative goal directed therapy (GDT) was effective only in higher control mortality rates (> 20%) with a relatively high heterogeneity that limited the strength of evidence. The aim of the present meta-analysis was to clearly understand which high risk patients may benefit of GDT.EVIDENCE ACQUISITION: Systematic review of randomized controlled trials with meta-analyses, including a meta-regression technique. MEDLINE, EMBASE, and The Cochrane Library databases were searched (1980-January 2015). Trials enrolling adult surgical patients and comparing the effects of GDT versus standard hemodynamic therapy were considered. The primary outcome measure was mortality. Data synthesis was obtained by using Odds Ratio (OR) with 95% confidence interval (CI) by random-effects model.EVIDENCE SYNTHESIS: Fifty eight studies met the inclusion criteria (8171 participants). Pooled OR for mortality was 0.70 (95% CI 0.56-0.88, P= 0.002, no statistical heterogeneity). GDT significantly reduced mortality when it is > 10% in control group (OR 0.43, 95% CI 0.30-0.61, P< 0.00001). The meta-regression model showed that the cut off of 10% of mortality rate in control group significantly differentiates 43 studies from the other 15, with a regression coefficient b of -0.033 and a P value of 0.0001. The significant effect of GDT was driven by high risk of bias studies (OR 0.48, 95% CI 0.34-0.67, P< 0.0001).CONCLUSIONS: The present meta-analysis, adopting the meta-regression technique, suggests that GDT significantly reduces mortality even when the event control rate is > 10%

Acute Kidney Injury in Coronavirus Disease 2019 Infected Patients: A Meta-Analytic Study

Introduction: In clinical reports on coronavirus disease 2019 (COVID-19), the incidence of acute kidney injury (AKI) is extremely variable, although AKI is described as an independent risk factor for mortality. A meta-analysis was performed to clarify the incidence and the impact of COVID-19-related AKI on mortality. Methods: All trials reporting the incidence of AKI in COVID-19 patients were searched using MEDLINE, the Cochrane Library, and EMBASE databases (last update April 26, 2020). Results: Ten trials with a sample of 5,166 patients were included. AKI occurred in 947 out of 5,166 (18.3%) patients. AKI incidence was higher in severe cases: 62/305 severe patients developed AKI (20%) versus 27/1,268 nonsevere patients (2%) (p = 0.00001). AKI occurred in 475 out of 915 (52%) deceased patients versus 183 out of 2,678 (7%) survivors (p = 0.00001). Continuous renal replacement therapy was significantly more frequent in severe cases and in dead patients. Conclusion: A significant increase in mortality rate was observed in COVID patients who developed AKI, and AKI incidence was also higher in severe cases. Any supportive strategies to protect kidney could represent valuable intervention to reduce mortality in severe COVID-19 patients

Vasopressor-Sparing Action of Methylene Blue in Severe Sepsis and Shock: A Narrative Review

Shock is a serious acute circulatory failure leading to inadequate oxygen delivery to the cells. Its treatment is mainly based on circulating fluid optimization, and vasopressors to provide an adequate mean arterial pressure and microcirculatory flow. Norepinephrine is the drug of choice, but high dosages may be responsible for several side effects, including increased myocardial oxygen consumption, dysrhythmias, and peripheral and organ ischemia. Moreover, some patients are “non-responders” to first-line norepinephrine treatment. Hence, other drugs have been proposed to reach and maintain the hemodynamic target. In general, they are described as catecholamine-sparing agents. Among others, the most used are vasopressin, corticosteroids, and angiotensin II. Methylene blue (MB) represents a further option, even though its use is still a topic of controversy. This review article tries to summarize what is known and unknown about the actions of MB in patients in shock. It reduces excessive production of nitric oxide via blockade of guanylate cyclase in shock states. At present, it appears the MB provides positive results in septic shock, if administered early. Further randomized controlled trials are warranted regarding its use to provide more precise indications to physicians involved in the treatment of such patients

LOFAR discovery of a 700-kpc remnant radio galaxy at low redshift

Remnant radio galaxies represent the final dying phase of radio galaxy evolution, in which the jets are no longer active. Due to their rarity in flux limited samples and the difficulty of identification, this dying phase remains poorly understood and the luminosity evolution largely unconstrained. Here we present the discovery and detailed analysis of a large (700 kpc) remnant radio galaxy with a low surface brightness that has been identified in LOFAR images at 150 MHz. By combining LOFAR data with new follow-up Westerbork observations and archival data at higher frequencies, we investigated the source morphology and spectral properties from 116 to 4850 MHz. By modelling the radio spectrum we probed characteristic timescales of the radio activity. The source has a relatively smooth, diffuse, amorphous appearance together with a very weak central compact core which is associated with the host galaxy located at z=0.051. From our ageing and morphological analysis it is clear that the nuclear engine is currently switched off or, at most, active at a very low power state. The host galaxy is currently interacting with another galaxy located at a projected separation of 15 kpc and a radial velocity offset of 300 km/s. This interaction may have played a role in the triggering and/or shut down of the radio jets. The spectral shape of this remnant radio galaxy differs from the majority of the previously identified remnant sources, which show steep or curved spectra at low to intermediate frequencies. In light of this finding and in preparation for new-generation deep low-frequency surveys, we discuss the selection criteria to be used to select representative samples of these sources.Comment: 10 pages, 6 figures, 5 tables, A&A accepte

Multi-frequency characterisation of remnant radio galaxies in the Lockman Hole field

Context. Remnant radio galaxies represent an important phase in the life-cycle of radio active galactic nuclei. It is suggested that in this phase, the jets have switched off and the extended emission is fading rapidly. This phase is not well-studied due to the lack of statistical samples observed at both low and high frequencies. Aims. In this work, we study a sample of 23 candidate remnant radio galaxies previously selected using the Low Frequency Array at 150 MHz in the Lockman Hole field. We examine their morphologies and study their spectral properties to confirm their remnant nature and revise the morphological and spectral criteria used to define the initial sample. Methods. We present new observations with the Karl G. Jansky Very Large Array at 6000 MHz at both high and low resolution. These observations allowed us to observe the presence or absence of cores and study the spectral curvature and steepness of the spectra of the total emission expected at these high frequencies for the remnant candidates. Results. We confirm 13 out of 23 candidates as remnant radio sources. This corresponds to 7% of the full sample of active, restarted, and remnant candidates from the Lockman Hole field. Surprisingly, only a minority of remnants reside in a cluster (23%). The remnant radio galaxies show a range of properties and morphologies. The majority do not show detection of the core at 6000 MHz and their extended emission often shows ultra-steep spectra (USS). However, there are also remnants with USS total emission and a detection of the core at 6000 MHz, possibly indicating a variety of evolutionary stages in the remnant phase. We confirm the importance of the combination of morphological and spectral criteria and this needs to be taken into consideration when selecting a sample of remnant radio sources

O Programa PROAMBIENTE na Transamazônica: lições aprendidas.

O objetivo desse artigo é apontar e discutir algumas lições deixadas pelo PROAMBIENTE, programa federal de apoio ao fortalecimento da agricultura familiar na Amazônia brasileira. O local de realização da pesquisa foi o polo transamazônica localizado na região de integração do Xingu, estado do Pará. Através de entrevistas aplicadas aos agricultores familiares, assim como a atores institucionais que participaram do período em que o programa esteve na região (2002 - 2006), chegou-se a um conjunto de lições que devem ser consideradas para o êxito de programas que visem o desenvolvimento rural. São elas: i. Necessidade de seleção de agricultores com real interesse e capacidade de assumir riscos; ii. Eliminação da cultura assistencialista; iii. Prioridade de atividades chaves: o caso do pagamento por serviços ambientais; iv. Utilização de uma nova abordagem do sistema produtivo; v. Assistência técnica e extensão rural com enfoque inovador; vi. Fortalecimento das organizações rurais locais; vii. Investimento na verticalização da produção; viii. O cuidado na geração de expectativas

Nuclear regions as seen with LOFAR international baselines: A high-resolution study of the recurrent activity

Context. Radio galaxies dominate the sky at radio wavelengths and represent an essential piece in the galaxy evolution puzzle. High-resolution studies focussed on statistical samples of radio galaxies are expected to shed light on the triggering mechanisms of the active galactic nucleus in their centre, alternating between the phases of activity and quiescence.Aims. For this work, we zoomed in on the sub-arcsec radio structures in the central regions of the 35 radio galaxies in the area covering 6.6 deg2 of the Lockman Hole region. The sources studied here were previously classified as active, remnant, and candidate restarted radio galaxies based on the LOw Frequency ARray (LOFAR) observations at 150 MHz. We examined the morphologies and studied the spectral properties of their central regions to explore their evolutionary stages and to revise the morphological and spectral criteria used to select the initial sample.Methods. We used the newly available LOFAR 150 MHz image obtained using international baselines, yielding a resolution of 0.38″ × 0.30″, making this the first systematic study of the nuclear regions at such a high resolution and low frequency. We used publicly available images from the Faint Images of the Radio Sky at Twenty-cm survey at 1.4 GHz and the Karl G. Jansky Very Large Array (VLA) Sky Survey at 3 GHz to achieve our goals. In addition, for one of the restarted candidates, we present new dedicated observations with the VLA at 3 GHz.Results. We characterised the central regions of the radio galaxies in our sample and found various morphologies, some even mimicking well-known double-double radio galaxies but on a smaller scale, that is, a few tens of kiloparsecs for the size of the restarted activity. We also see the beginnings of active jets or distinct detections unrelated to the large-scale structure. Furthermore, we found a variety of radio spectra characterising the sources in our sample, such as flat, steep, or peaked in the frequency range between 150 MHz and 3 GHz, indicative of the different life-cycle phases of the sources in our sample. Based on these analyses, we confirm five out of six previously considered restarted candidates and identify three more restarted candidates from the active sample. As the number of restarted candidates still exceeds that of remnant candidates, this is consistent with previous results suggesting that the restarted phase can occur after a relatively short remnant phase (i.e. a few tens of millions of years)

Pathophysiology of musculoskeletal pain: a narrative review

Musculoskeletal pain (excluding bone cancer pain) affects more than 30% of the global population and imposes an enormous burden on patients, families, and caregivers related to functional limitation, emotional distress, effects on mood, loss of independence, and reduced quality of life. The pathogenic mechanisms of musculoskeletal pain relate to the differential sensory innervation of bones, joints, and muscles as opposed to skin and involve a number of peripheral and central nervous system cells and mediators. The interplay of neurons and non-neural cells (e.g. glial, mesenchymal, and immune cells) amplifies and sensitizes pain signals in a manner that leads to cortical remodeling. Moreover, sex, age, mood, and social factors, together with beliefs, thoughts, and pain behaviors influence the way in which musculoskeletal pain manifests and is understood and assessed. The aim of this narrative review is to summarize the different pathogenic mechanisms underlying musculoskeletal pain and how these mechanisms interact to promote the transition from acute to chronic pain