Urine biochemistry assessment in the sequential evaluation of renal function: Time to think outside the box

Urine biochemistry (UB) remains a controversial tool in acute kidney injury (AKI) monitoring, being considered to be of limited value both in terms of AKI diagnosis and prognosis. However, many criticisms can be made to the studies that have established the so called “pre-renal paradigm” (used for decades as the essential physiological basis for UB assessment in AKI) as well as to more recent studies suggesting that UB has no utility in daily clinical practice. The aim of this article is to describe our hypothesis on how to interpret simple and widely recognized urine biochemical parameters from a novel perspective, propose the rationale for their sequential assessment and demonstrate their usefulness in AKI monitoring, especially in the critical care setting

High lactate levels are predictors of major complications after cardiac surgery

ObjectiveAlthough hyperlactatemia after cardiac surgery is common, the implications of raised levels remain controversial. The aim of this study was to evaluate whether high lactate levels after cardiac surgery are predictors of major complications including mortality.Patients and MethodsThis was a substudy of TRACS (Transfusion Requirements After Cardiac Surgery), which was designed as a prospective, randomized, controlled trial evaluating the effects of a transfusion strategy on morbidity and mortality.ResultsOf the 502 patients enrolled, 52 (10%) had at least 1 major complication. Patients with complications were older, had a higher EuroSCORE, lower left ventricular ejection fraction, lower preoperative hemoglobin, a higher prevalence of renal disease, and received more blood transfusions than the group without complications. Lactate levels were higher in the group with complications at the end of surgery (3.6 mmol/L [2.8-5.1] vs 3.3 mmol/L [2.2-4.8]; P = .018), immediately after intensive care unit (ICU) admission (0 hour) (4.4 mmol/L [3.1-8.4] vs 4 mmol/L [2.6-6.4]; P = .048); 6 hours (4 mmol/L [2.7-5.8] vs 2.6 mmol/L [2-3.6], P < .001), and 12 hours after admission (2.3 mmol/L [1.8-3.2] vs 1.7 mmol/L [1.3-2]; P < .001). In a multivariate model, higher age (odds ratio [OR], 1.048, 95% confidence interval [CI], 1.011-1.086; P = .010), left ventricular ejection fraction (LVEF) lower than 40% (OR, 3.03; 95% CI, 1.200-7.510; P = .019 compared with LVEF of 40%-59%; OR, 3.571; 95% CI, 1.503-8.196; P = .004 compared with LVEF higher than 60%), higher EuroSCORE (OR, 1.138; 95% CI; 1.007-1.285; P = .038), red blood cell transfusion (OR, 1.230; 95% CI, 1.086-1.393; P = .001), and lactate levels 6 hours after ICU admission (OR, 3.28, 95% CI; 1.61-6.69; P = .001) are predictors of major complications.ConclusionsHyperlactatemia 6 hours after ICU admission is an independent risk factor for worse outcomes in adult patients after cardiac surgery

Disinfection of Orthodontic Elastomers and Its Effects on Tensile Strength

Objective: This study aimed to investigate the effect of different disinfection protocols on the mechanical properties of orthodontic elastomeric ligatures (EL), an important issue to biosafety improvement and infection control, and to avoid cross-contamination.Methods: A total of 120 EL were randomly divided into 6 experimental groups (n = 20) according to the disinfection method employed: group 1, EL were not immersed in a disinfectant solution (control group); group 2, EL were immersed in 2% glutaraldehyde; group 3, EL were immersed in 70% alcohol solution; group 4, EL were cleaned in an ultrasound washing (UW) machine by immersion in 0.5% enzyme detergent solution; group 5, UW procedure was performed, followed by immersion in 2% glutaraldehyde; Group 6, UW procedure was performed, followed by immersion in 70% alcohol. After disinfection, EL were subjected to a tensile strength test where the maximum strength, maximum elongation, and work at failure were determined. Data were statistically evaluated using one-way ANOVA and Dunnett’s t-test for multiple comparisons.Results:Statistically significant different (P < .05) values were found between the disinfection methods, and 70% alcohol showed negative changes in all mechanical properties of orthodontic elastomers. By contrast, 2% glutaraldehyde did not show significant alteration in mechanical properties, whereas the UW procedure showed significant alteration in maximum strength and work at failure.Conclusion:Of the tested substances for disinfection, 2% glutaraldehyde was the only substance that did not cause significant changes in the mechanical properties of orthodontic elastics and is considered as an alternative for elastic disinfection before its use

Atividade Eletromiográfica dos Músculos da Mastigação em Indivíduos com Mordida Cruzada Posterior / Electromyographic Activity of Masticatory Muscles in Patients with Posterior Crossbite

Objetivo: Revisar a literatura sobre eletromiografia dos músculos da mastigação em indivíduos com mordida cruzada posterior (MCP). Metodologia: Busca na base de dados Pubmed, utilizando os descritores “posterior crossbite” e “electromyography”. A busca foi limitada a periódicos revisados por pares e compreendeu apenas artigos publicados nos últimos 10 anos em língua inglesa. Resultados: Quatorze artigos científicos sobre eletromiografia dos músculos da mastigação e MCP foram incluídos neste estudo. A atividade eletromiográfica nos músculos da mastigação em indivíduos com MCP é amplamente investigada. No entanto, resultados controversos foram encontrados em relação à atividade muscular. A divergência dos resultados encontrados é atribuída ao tamanho e à idade da amostra, assim como à metodologia empregada na avaliação eletromiográfica. Conclusão: A mordida cruzada posterior está associada às alterações na atividade nos músculos temporal anterior (TA) e masseter superficial (Ms). Carecem, no entanto, evidências conclusivas sobre como essas alterações impactam o desempenho muscular e a performance mastigatória. Ensaios clínicos randomizados com maior número amostral e tempo de acompanhamento são necessários para confirmarem as alterações eletromiográficas nesses indivíduos

Diaphragmatic pacing stimulation in spinal cord injury: anesthetic and perioperative management

OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results

High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period

Blood transfusion in cardiac surgery is a risk factor for increased hospital length of stay in adult patients

Abstract\ud \ud \ud \ud Background\ud \ud Allogeneic red blood cell (RBC) transfusion has been proposed as a negative indicator of quality in cardiac surgery. Hospital length of stay (LOS) may be a surrogate of poor outcome in transfused patients.\ud \ud \ud \ud Methods\ud \ud Data from 502 patients included in Transfusion Requirements After Cardiac Surgery (TRACS) study were analyzed to assess the relationship between RBC transfusion and hospital LOS in patients undergoing cardiac surgery and enrolled in the TRACS study.\ud \ud \ud \ud Results\ud \ud According to the status of RBC transfusion, patients were categorized into the following three groups: 1) 199 patients (40%) who did not receive RBC, 2) 241 patients (48%) who received 3 RBC units or fewer (low transfusion requirement group), and 3) 62 patients (12%) who received more than 3 RBC units (high transfusion requirement group). In a multivariable Cox proportional hazards model, the following factors were predictive of a prolonged hospital length of stay: age higher than 65 years, EuroSCORE, valvular surgery, combined procedure, LVEF lower than 40% and RBC transfusion of > 3 units.\ud \ud \ud \ud Conclusion\ud \ud RBC transfusion is an independent risk factor for increased LOS in patients undergoing cardiac surgery. This finding highlights the adequacy of a restrictive transfusion therapy in patients undergoing cardiac surgery.\ud \ud \ud \ud Trial registration\ud \ud Clinicaltrials.gov identifier: http://NCT01021631.The authors would like to thank Suelly Zeferino and Lígia Camara for their assistance with data extraction. There was no external funding source for this research.This work was supported by the Department of Anaesthesiology, InCor, University of Sao Paulo

Training future generations to deliver evidence-based conservation and ecosystem management

1. To be effective, the next generation of conservation practitioners and managers need to be critical thinkers with a deep understanding of how to make evidence-based decisions and of the value of evidence synthesis. 2. If, as educators, we do not make these priorities a core part of what we teach, we are failing to prepare our students to make an effective contribution to conservation practice. 3. To help overcome this problem we have created open access online teaching materials in multiple languages that are stored in Applied Ecology Resources. So far, 117 educators from 23 countries have acknowledged the importance of this and are already teaching or about to teach skills in appraising or using evidence in conservation decision-making. This includes 145 undergraduate, postgraduate or professional development courses. 4. We call for wider teaching of the tools and skills that facilitate evidence-based conservation and also suggest that providing online teaching materials in multiple languages could be beneficial for improving global understanding of other subject areas.Peer reviewe