Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial

Background: There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. Methods: In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). Results: We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). Conclusions: Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Linkage analysis of Mendelian forms of complex disorders in a South American population

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Genetic power of a Brazilian three-generation family with generalized aggressive periodontitis

Aggressive periodontitis is a multifactorial disease with strong familial aggregation. Genetic linkage analysis is a method to localize causative or predisposing genes along the chromosome, thus helping to unravel important pathogenic pathways. Prior to applying this method, however, it is essential to estimate the power of the study design. The aim of this study was to estimate the power of a large Brazilian family with generalized aggressive periodontitis (GAgP) for future linkage analysis. A three-generation family was seen at the Dental School of the Federal University of Bahia. A full-mouth periodontal probing at 6 sites/tooth was performed in all 23 family members. Five out of 10 siblings were affected with GAgP. A parametric simulation (? = 0) was performed on 100 replicates using the statistical software SLINK for linkage analysis. The linkage LOD score criteria for complex diseases described by Haines was adopted. There was maximum expected LOD scores of 3.56 and 3.48 at penetrance rate F = 0.98, and both studied phenocopy rates p=0.0 and p=0.02, respectively. The analyzed family showed statistical power for future genetic linkage analysis of candidate genes to GAgP

Minimal

Minimal es una marca de accesorios para hombres que promueve la seguridad y la autoestima de ellos. En el trabajo se desarrolló una estrategia de marketing digital, mezclado con herramientas del marketing tradicional con el fin de posicionar Minimal dentro del mercado objetivo identificando los objetivos de la estrategia, analizando la competencia digital, planteando los contenidos a aplicar y definiendo el buyer persona adecuado. Asimismo, se construyó la propuesta de la estrategia de marketing la cual incluye un posicionamiento SEO y SEM en Google, el desarrollo de una página web, las estrategias de publicidad y anuncios en internet ideales para la marca, la estrategia en redes sociales, el email marketing, y el uso del marketing de proximidad.Minimal is a men's accessories brand that promotes their safety and self-esteem. Through this paper, a digital marketing strategy was developed, mixed with traditional marketing tools in order to position Minimal within the target market, identifying the objectives of the strategy, analyzing digital competition, proposing the content to apply and defining the appropriate buyer persona. Likewise, the marketing strategy proposal was built, which includes SEO and SEM positioning in Google, the development of a web page, advertising strategies and internet ads ideal for the brand, the strategy in social networks, email marketing, and the use of proximity marketing

Hypercholermic metabolic alcalsosis as a presentation of cystic fibrosis: presentation of two cases = Alcalosis metabólica hipoclorémica como presentación de la fibrosis quística. Informe de dos casos

Introduction: We describe two cases of patients with hyperchloremic metabolic acidosis as an initial presentation of cystic fibrosis (CF) or as part of a second CF exacerbation. Clinical Cases: Two patients, 6 and 9 months old, consulted for cough, fever, and dyspnea. The first had syndrome of recurrent bronchial obstruction, without a diagnosis of CF on admission. Both presented with difficulty breathing, dehydration, and malnutrition. Arterial blood gases showed metabolic acidosis, hypokalemia, and severe hypochloremia. Treatment with sodium chloride and potassium improved their electrolyte balance and acid-base status. They did not present with renal or gastrointestinal losses of chloride. CF and pseudo-Barter’s Syndrome were diagnosed. Conclusion: Metabolic alkalosis can present as an initial manifestation of CF in infants with recurrent bronchiolitis and short stature suspected of having CF: equally it can be an acute exacerbation in patients with known CF. Your recognition and treatment are an opportunity to decrease morbidity

Alelos HLA-II clásicos en niños con diabetes mellitus tipo 1 del noroccidente de Colombia

RESUMEN: Antecedentes: La diabetes mellitus tipo 1 (T1D) es una enfermedad crónica frecuente en la infancia. Esta enfermedad tiene mayor incidencia en los europeos que otras poblaciones. La fisiopatología se explica por la interacción de factores genéticos, inmunológicos y ambientales. Los principales determinantes genéticos son los alelos HLA-DRB1 y HLA-DQB1, la mayoría descritos en la población europea. Sin embargo, esto no se ha estudiado adecuadamente en la población colombiana. Objetivo: nuestro objetivo fue describir los alelos HLA clase II más comunes en pacientes colombianos con T1D. Metodología: A noventa y seis pacientes con T1D del noroccidente de Colombia les fueron secuenciados los exones 2 de los genes HLA-DRB1 y HLA-DQB1 por tipificación basada en secuencias. La asignación de alelos fue realizada por el software SBTengine. El estado inmunitario se clasificó de acuerdo al resultado de autoanticuerpos anti-GAD-65 y anti-IA-2. Resultados: La edad promedio de inicio fue de 8,06 años, 8,6% tenía un padre con T1D y 7,29% tenía al menos un hermano enfermo. La edad de inicio del 25% fue antes de los cinco años. Los alelos más frecuentes fueron DRB1 * 03: 01 (0,225), DRB1 * 14: 141 (0,10), DQB1 * 06: 123 (0,22) y DQB1 * 02: 01 (0,18). Los alelos de riesgo descritos en la población europea que se encontraron en nuestros pacientes fueron DQB1 * 02: 01 (0,18) y DRB1 * 03: 01 (0,225). El 65,63% tenía anti-IA-2, anti-GAD65 o ambos positivos, es decir, tenían diabetes autoinmune, mientras que en el 29,17% no se identificó ningún anticuerpo. Conclusiones: Encontramos que los alelos más frecuentes en individuos con T1D en la región noroccidental de Colombina fueron DRB1 * 03: 01, DRB1 * 14: 141, DQB1 * 06: 123 y DQB1 * 02: 01. Se describieron dos alelos de riesgo HLA de población europea en nuestros pacientes (DQB1*02:01 y DRB1*03:01) y un alelo de riesgo descrito en Latinoamérica (DRB1*14)ABSTRACT: Background: Type 1 Diabetes Mellitus is a frequent chronic disease in childhood. This disease has a higher incidence in Europeans than other populations. The pathophysiology is explained by the interaction of genetic, immunological and environmental factors. The major genetic determinants are HLA-DRB1 and DQB1 alleles, most are described in European population. However, this has not been adequately studied in Colombian population. Aim: Our aim was to describe most common HLA alleles in colombian patients with T1D. Methodology: Ninety-six patients with T1D from northwest Colombia were typed for the DRB1 and DQB1 genes by sequence-based typing, the allele assignment was performed by SBTengine software. Immune status was classified according to testing for anti-GAD-65 and anti-IA-2. Results: The mean age at onset was 8.06 years, 8.6% had a parent with T1D and 7.29% had a brother. The onset age of 25% was before five years. The most frequent alleles were DRB1* 03: 01 (0.225), DRB1 * 14: 141 (0.10), DQB1 * 06: 123 (0.22) y DQB1 * 02: 01 (0.18). The risk alleles described in European population that were found in our patients were fueron DQB1 * 02: 01 (0.18) y DRB1 * 03: 01 (0.225). The 65.63% had IA-2, GAD65 or both positive, that is, they were autoimmune diabetes, while in 29.17% no antibody was identified. Conclusions: We found that the most frequent alleles in individuals with T1D in the northwestern region of Colombina were DRB1 * 03: 01, DRB1 * 14: 141, DQB1 * 06: 123 and DQB1 * 02: 01. Two HLA risk alleles from the European population were described in our patients DQB1 * 02: 01 and DRB1 * 03: 01 and one risk allele described in Latin America (DRB1*14