Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Design and baseline characteristics of the finerenone in reducing cardiovascular mortality and morbidity in diabetic kidney disease trial

Background: Among people with diabetes, those with kidney disease have exceptionally high rates of cardiovascular (CV) morbidity and mortality and progression of their underlying kidney disease. Finerenone is a novel, nonsteroidal, selective mineralocorticoid receptor antagonist that has shown to reduce albuminuria in type 2 diabetes (T2D) patients with chronic kidney disease (CKD) while revealing only a low risk of hyperkalemia. However, the effect of finerenone on CV and renal outcomes has not yet been investigated in long-term trials. Patients and Methods: The Finerenone in Reducing CV Mortality and Morbidity in Diabetic Kidney Disease (FIGARO-DKD) trial aims to assess the efficacy and safety of finerenone compared to placebo at reducing clinically important CV and renal outcomes in T2D patients with CKD. FIGARO-DKD is a randomized, double-blind, placebo-controlled, parallel-group, event-driven trial running in 47 countries with an expected duration of approximately 6 years. FIGARO-DKD randomized 7,437 patients with an estimated glomerular filtration rate >= 25 mL/min/1.73 m(2) and albuminuria (urinary albumin-to-creatinine ratio >= 30 to <= 5,000 mg/g). The study has at least 90% power to detect a 20% reduction in the risk of the primary outcome (overall two-sided significance level alpha = 0.05), the composite of time to first occurrence of CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. Conclusions: FIGARO-DKD will determine whether an optimally treated cohort of T2D patients with CKD at high risk of CV and renal events will experience cardiorenal benefits with the addition of finerenone to their treatment regimen. Trial Registration: EudraCT number: 2015-000950-39; ClinicalTrials.gov identifier: NCT02545049

Hip�tesis del intervalo din�mico de los aprendizajes humanos

16 p�ginasLos aprendizajes humanos son definidos en su din�mica de adaptaci�n mediante procesos de asimilaci�n y acomodaci�n. Estos procesos no son est�ticos, ya que implican estados con respecto al tiempo. Por lo tanto, se puede sostener el argumento de la cinem�tica cognitiva, o, dicho de otra manera, cinem�tica de los aprendizajes humanos. Este trabajo exhibe la variabilidad de los aprendizajes humanos, a trav�s de t�cnicas matem�ticas como la estad�stica, en espec�fico, el Coeficiente de Variaci�n (CV). Se estableci� una relaci�n con la experiencia de los autores vivenciales para incorporar la mirada fenomenol�gica en la comprensi�n de este constructo. Con la resoluci�n experimental de cinco casos, se gener� naturalmente una curva con un intervalo exponencial, lo cual es caracter�stico de la evoluci�n del aprendizaje. Adem�s, se establecieron el dinamismo y la singularidad como estructuras generales y fundantes de la experiencia de los aprendizajes humanos

Modelo psicopedag�gico para la din�mica cognitiva del aprendizaje humano

25 p�ginasLa Psicopedagog�a centra su inter�s en estudiar y comprender el aprendizaje de los seres humanos, desde sus diversas manifestaciones y subjetividades. El aprendizaje humano est� ligado a una perspectiva compleja, en cuanto a sistema ca�tico, por lo que las formas de abordarlo pueden ser de diversas l�neas del conocimiento. El objetivo de este trabajo fue, desde un an�lisis metacient�fico, establecer la relaci�n sujeto-objeto en torno al aprendizaje humano y construir un modelo algebraico que permitiera el reconocimiento de una estructura l�gica, sus manifestaciones, trayectorias, posibilidades e imposibilidades de determinaci�n matem�tica, bas�ndonos en las propuestas de Piaget, Ebbinghaus y Spearman. Los modelos construidos permitieron establecer relaciones sujeto-objeto reconociendo sus complejidades y propiedades, desafiando al an�lisis psicopedag�gico a una nueva comprensi�n de los alcances de la l�gica en el modelado del aprendizaje y el concepto de umbral

Gu?a r?pidas de consultor?a telef?nica m?dica y de enfermer?a

Gu?a de consulta para o persoal m?dico e de enfermar?a que desenvolve o seu traballo en centros de coordinaci?n telef?nica para a atenci?n ?s urxencias e ?s emerxencias sanitarias. Est? estruturada en 12 cap?tulos nos que describen os principais protocolos de actuaci?n para a asistencia ?s patolox?as m?is com?ns atendidas no ?mbito de urxencias extra hospitalarias.Gu?a de consulta para el personal m?dico y de enfermer?a que desarrolla su trabajo en centros de coordinaci?n telef?nica para la atenci?n a las urgencias y a las emergencias sanitarias. Est? estructurada en 12 cap?tulos en los que describen los principales protocolos de actuaci?n para la asistencia a las patolog?as m?s comunes atendidas en el ?mbito de urgencias extra hospitalarias

Aspiration risk factors, microbiology, and empiric antibiotics for patients hospitalized with community-acquired pneumonia

Background: Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. Research question: What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? Study design and methods: This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. Results: We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P = .021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P 50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. Interpretation: Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage