Benefícios após implementação de um protocolo de "Patient Blood Management"

Objectivo: Frequentemente os doentes avaliados no contexto de cirurgia electiva apresentam anemias que, caso não sejam corrigidas, irão aumentar o risco de mortalidade e morbilidade pós-cirúrgica, de infecções, de necessidade de transfusões de componentes sanguíneos (CS) e do aumento do tempo de hospitalização 1 . O Patient Blood Mangement (PBM) é uma abordagem baseada na evidência e multidisciplinar que visa optimizar os cuidados oferecidos ao doente cirúrgico, adotando- se medidas de otimização que permitam minimizar a necessidade de transfusão de CS, nomeadamente Concentrados Eritrocitários (CEs). Estas medidas têm lugar, em todo o período peri-operatório. O PBM engloba uma equipa multidisciplinar centrada no doente e um dos seus objetivos é a otimização dos valores de Hb pré- cirúrgicos, no doente proposto para cirurgia programada. Pretendemos partilhar os resultados obtidos, após implementação de um protocolo de PBM entre o Serviço de Sangue e Medicina Transfusional e o da Cirurgia B do HFF, em que, entre outros parâmetros, é analisada a eventual necessidade de correção de anemias ferropénicas. Material e métodos: Foram englobados neste estudo todos os pedidos de PBM desde a sua implementação em 2015 até Janeiro de 2017. Foram colhidos dados dos valores de Hemoglobina (Hb) de cada doente que efectuou consulta de PBM antes e após tratamento, endovenoso (ev), com ferro (Carboximaltose férrica - Ferinject ® ) e registada a necessidade transfusional de CEs no período peri-operatório. Resultados: Foram avaliados em consulta de PBM 40 doentes (90% com neoplasia gástrica ou colo-retal), 20 (50%) dos quais foram submetidos a cirurgia abdominal por laparotomia ou laparoscopia, dos restantes 20 (50%): 2 (10%) recusaram tratamento com ferro ev, 3 (15%) não necessitavam de tratamento cirúrgico, 3 (15%) recusaram cirurgia, 3 (15%) não apresentavam as condições clínicas para administração de ferro ev e os restantes 9 (45%) ainda aguardavam cirurgia. Durante este período ocorreram 3 óbitos, no grupo dos doentes que aguardavam cirurgia, resultantes da sua patologia de base. Dos 20 doentes operados, 52.3% eram do sexo feminino (♀) e 47.7% do sexo masculino (♂). A média da idade dos doentes estudados foi de 73 anos no ♀ e de 70 anos no ♂. O valor médio de Hb, registado, pré-tratamento com ferro ev foi de 10.1 g/dL e de 9.7 g/dL respetivamente para ♀ e ♂. Após um tratamento com ferro ev os valores de Hb subiram para 11.1 (♀) e 11.4 g/dL (♂). Do total de doentes submetidos a cirurgia, 2 foram transfundidos com concentrado eritrocitário (2CEs cada um) no período peri-operatório. Conclusões: Desde a sua implementação, parcial, no HFF, o PBM permitiu a otimização de doentes com anemia pré- operatória não tendo sido realizada transfusão de CE em 90% dos doentes sujeitos a cirurgia. O PBM é, em nosso entender, uma ferramenta essencial para a optimização dos doentes pré-cirúrgicos, permitindo uma racionalização dos recursos disponíveis em CEs e concomitantemente evitar potenciais efeitos adversos, à transfusão, nestes doentes já debilitados pela patologia de base. 1 Shander A. et al, "Patient Blood Management", British Journal of Anaesthesia, 109 (1): 55-68, (2012).N/

The First Episode Rapid Early Intervention for Eating Disorders - Upscaled study: Clinical outcomes

BACKGROUND: First Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway for emerging adults aged 16 to 25‐years with a recent onset eating disorder (ED) of <3 years. A previous single‐site study suggests that FREED significantly improves clinical outcomes compared to treatment‐as‐usual (TAU). The present study (FREED‐Up) assessed the scalability of FREED. A multi‐centre quasi‐experimental pre‐post design was used, comparing patient outcomes before and after implementation of FREED in participating services. METHODS: FREED patients (n = 278) were consecutive, prospectively ascertained referrals to four specialist ED services in England, assessed at four time points over 12 months on ED symptoms, mood, service utilization and cost. FREED patients were compared to a TAU cohort (n = 224) of similar patients, identified retrospectively from electronic patient records in participating services. All were emerging adults aged 16–25 experiencing a first episode ED of <3 years duration. RESULTS: Overall, FREED patients made significant and rapid clinical improvements over time. 53.2% of FREED patients with anorexia nervosa reached a healthy weight at the 12‐month timepoint, compared to only 17.9% of TAU patients (X2 [1, N = 107] = 10.46, p < .001). Significantly fewer FREED patients required intensive (i.e., in‐patient or day‐patient) treatment (6.6%) compared to TAU patients (12.4%) across the follow‐up period (X2 [1, N = 40] = 4.36, p = .037). This contributed to a trend in cost savings in FREED compared to TAU (−£4472, p = .06, CI −£9168, £233). DISCUSSION: FREED is robust and scalable and is associated with substantial improvements in clinical outcomes, reduction in inpatient or day‐patient admissions, and cost‐savin

Assessing implementation fidelity in the First Episode Rapid Early Intervention for Eating Disorders service model

BACKGROUND: The First Episode Rapid Early Intervention for Eating Disorders (FREED) service model is associated with significant reductions in wait times and improved clinical outcomes for emerging adults with recent-onset eating disorders. An understanding of how FREED is implemented is a necessary precondition to enable an attribution of these findings to key components of the model, namely the wait-time targets and care package. AIMS: This study evaluated fidelity to the FREED service model during the multicentre FREED-Up study. METHOD: Participants were 259 emerging adults (aged 16-25 years) with an eating disorder of <3 years duration, offered treatment through the FREED care pathway. Patient journey records documented patient care from screening to end of treatment. Adherence to wait-time targets (engagement call within 48 h, assessment within 2 weeks, treatment within 4 weeks) and care package, and differences in adherence across diagnosis and treatment group were examined. RESULTS: There were significant increases (16-40%) in adherence to the wait-time targets following the introduction of FREED, irrespective of diagnosis. Receiving FREED under optimal conditions also increased adherence to the targets. Care package use differed by component and diagnosis. The most used care package activities were psychoeducation and dietary change. Attention to transitions was less well used. CONCLUSIONS: This study provides an indication of adherence levels to key components of the FREED model. These adherence rates can tentatively be considered as clinically meaningful thresholds. Results highlight aspects of the model and its implementation that warrant future examination

Весовые соотношения тимуса и надпочечников у антенатально погибших плодов

ТИМУСНАДПОЧЕЧНИКИтимомегалиядети первого года жизнидети раннего возрастаМЛАДЕНЕЦ, СМЕРТНОСТЬЭНДОКРИННОЙ СИСТЕМЫ БОЛЕЗНИСМЕРТНОСТЬ ДЕТСКАЯсиндром внезапной детской смерт

Unprecedented within-species chromosome number cline in the Wood White butterfly Leptidea sinapis and its significance for karyotype evolution and speciation

Background: Species generally have a fixed number of chromosomes in the cell nuclei while between-species differences are common and often pronounced. These differences could have evolved through multiple speciation events, each involving the fixation of a single chromosomal rearrangement. Alternatively, marked changes in the karyotype may be the consequence of within-species accumulation of multiple chromosomal fissions/fusions, resulting in highly polymorphic systems with the subsequent extinction of intermediate karyomorphs. Although this mechanism of chromosome number evolution is possible in theory, it has not been well documented. Results: We present the discovery of exceptional intraspecific variability in the karyotype of the widespread Eurasian butterfly Leptidea sinapis. We show that within this species the diploid chromosome number gradually decreases from 2n = 106 in Spain to 2n = 56 in eastern Kazakhstan, resulting in a 6000 km-wide cline that originated recently (8,500 to 31,000 years ago). Remarkably, intrapopulational chromosome number polymorphism exists, the chromosome number range overlaps between some populations separated by hundreds of kilometers, and chromosomal heterozygotes are abundant. We demonstrate that this karyotypic variability is intraspecific because in L. sinapis a broad geographical distribution is coupled with a homogenous morphological and genetic structure. Conclusions: The discovered system represents the first clearly documented case of explosive chromosome number evolution through intraspecific and intrapopulation accumulation of multiple chromosomal changes. Leptidea sinapis may be used as a model system for studying speciation by means of chromosomally-based suppressed recombination mechanisms, as well as clinal speciation, a process that is theoretically possible but difficult to document. The discovered cline seems to represent a narrow time-window of the very first steps of species formation linked to multiple chromosomal changes that have occurred explosively. This case offers a rare opportunity to study this process before drift, dispersal, selection, extinction and speciation erase the traces of microevolutionary events and just leave the final picture of a pronounced interspecific chromosomal difference

Brane-World Gravity

The observable universe could be a 1+3-surface (the "brane") embedded in a 1+3+\textit{d}-dimensional spacetime (the "bulk"), with Standard Model particles and fields trapped on the brane while gravity is free to access the bulk. At least one of the \textit{d} extra spatial dimensions could be very large relative to the Planck scale, which lowers the fundamental gravity scale, possibly even down to the electroweak ($\sim$ TeV) level. This revolutionary picture arises in the framework of recent developments in M theory. The 1+10-dimensional M theory encompasses the known 1+9-dimensional superstring theories, and is widely considered to be a promising potential route to quantum gravity. At low energies, gravity is localized at the brane and general relativity is recovered, but at high energies gravity "leaks" into the bulk, behaving in a truly higher-dimensional way. This introduces significant changes to gravitational dynamics and perturbations, with interesting and potentially testable implications for high-energy astrophysics, black holes, and cosmology. Brane-world models offer a phenomenological way to test some of the novel predictions and corrections to general relativity that are implied by M theory. This review analyzes the geometry, dynamics and perturbations of simple brane-world models for cosmology and astrophysics, mainly focusing on warped 5-dimensional brane-worlds based on the Randall--Sundrum models. We also cover the simplest brane-world models in which 4-dimensional gravity on the brane is modified at \emph{low} energies -- the 5-dimensional Dvali--Gabadadze--Porrati models. Then we discuss co-dimension two branes in 6-dimensional models.Comment: A major update of Living Reviews in Relativity 7:7 (2004) "Brane-World Gravity", 119 pages, 28 figures, the update contains new material on RS perturbations, including full numerical solutions of gravitational waves and scalar perturbations, on DGP models, and also on 6D models. A published version in Living Reviews in Relativit

Observation of associated near-side and away-side long-range correlations in √sNN=5.02 TeV proton-lead collisions with the ATLAS detector

Two-particle correlations in relative azimuthal angle (Δϕ) and pseudorapidity (Δη) are measured in √sNN=5.02  TeV p+Pb collisions using the ATLAS detector at the LHC. The measurements are performed using approximately 1  μb-1 of data as a function of transverse momentum (pT) and the transverse energy (ΣETPb) summed over 3.1<η<4.9 in the direction of the Pb beam. The correlation function, constructed from charged particles, exhibits a long-range (2<|Δη|<5) “near-side” (Δϕ∼0) correlation that grows rapidly with increasing ΣETPb. A long-range “away-side” (Δϕ∼π) correlation, obtained by subtracting the expected contributions from recoiling dijets and other sources estimated using events with small ΣETPb, is found to match the near-side correlation in magnitude, shape (in Δη and Δϕ) and ΣETPb dependence. The resultant Δϕ correlation is approximately symmetric about π/2, and is consistent with a dominant cos⁡2Δϕ modulation for all ΣETPb ranges and particle pT