Heart Rate Variability for Outcome Prediction in Intracerebral and Subarachnoid Hemorrhage: A Systematic Review

This systematic review presents clinical evidence on the association of heart rate variability with outcome prediction in intracerebral and subarachnoid hemorrhages. The literature search led to the retrieval of 19 significant studies. Outcome prediction included functional outcome, cardiovascular complications, secondary brain injury, and mortality. Various aspects of heart rate recording and analysis, based on linear time and frequency domains and a non-linear entropy approach, are reviewed. Heart rate variability was consistently associated with poor functional outcome and mortality, while controversial results were found regarding the association between heart rate variability and secondary brain injury and cardiovascular complications

Capacidad predictiva de un modelo farmacocinético de infusión continua con ajuste manual de sevoflurano líquido por medio del sistema AnaConDa (Anesthetic Conserving Device)

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid. Facultad de Medicina, Departamento de Medicina. Fecha de lectura: 24 de Octubre de 2011

Principales creencias sexuales disfuncionales en mayores

Introduction: Hypersexual disorder is a clinical diagnosis characterised by an ex- cessive sexual desire, together with a pathological inability to control it. It is esti- mated that this clinical diagnosis could affect about 6% of the total population, although this figure varies according to the instrument used for its diagnosis. One of the most important problems when accurately estimating its prevalence is related to the use of non-validated assessment instruments. In order to overcome this limitation, the preliminary results of the Spanish translation of the Hypersexuality Inventory (IH) are presented herein. Method: For this purpose, 600 young adults (300 males and 300 females) aged 18-27 years old completed a translated and adapted version of the IH, together with other instruments to assess sexual compulsivity. Results: By a factor analysis, we found that the IH comprised three subscales that explained 55.5% of variance. This factorial structure was confirmed through confirmatory factor analyses (X2 = 239.4; G.L. = 145; X2/G.L. = 1.65; rmsea = .03 [90%CI = .02 - .04]). Reliability for the total score and subscales ranged between .79 and .91. The correlations be- tween the IH and related measures were positive and significant (r between .74 and .71). Conclusion: This results support the employment of the IH to assess hyper- sexuality among Spanish young adults and its superiority to other traditional meas- ures to assess its clinical diagnosis.Introducción: La sexualidad es una dimensión fundamental del ser humano e incluye el género, la identidad y la orientación sexual, el erotismo, la vinculación afectiva, el amor y la reproducción. Se manifiesta con pensamientos, fantasías, deseos, creencias, acti- tudes, valores, actividades prácticas, roles y relaciones y es el resultado de la interacción de múltiples factores. La respuesta sexual en mayores experimenta cambios con la edad. En este contexto, ciertas creencias disfuncionales sexuales pueden influir negati- vamente en el desarrollo de su sexualidad. Por ello nos planteamos conocer las princi- pales creencias disfuncionales sexuales femeninas (cdsf) en personas mayores y comprobar si están relacionadas con la edad y el nivel educativo y socioeconómico. Método: Treinta mujeres de la Universitat per a Majors de la Universitat Jaume I de Castellón con edades entre 54 y 79 años (media = 61,43; dt = 5,34) cumplimentaron el cuestionario de creencias sexuales disfuncionales femeninas (csdf, Nobre y Pinto- Gouveia, 2002). Resultados: Las principales csdf estuvieron relacionadas con el afec- to y el amor en la pareja, los sentimientos maternales, la edad y el conservadurismo sexual. No se halló correlación significativa con la edad o el nivel educativo y socioeco- nómico a excepción de la edad con la dimensión de «Creencias sobre la autoimagen» (r = 0,483; p = 0,007). Conclusión: Estos resultados indican que existen csdf que pue- den influir en la sexualidad de las personas. Así pues, con el objetivo de evitar la apari- ción de estas falsas creencias, prevenir trastornos sexuales y promocionar la salud sexual, la educación sexual sería relevante a lo largo de todo el ciclo vital

Ventilation Targets for Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review

Mechanical thrombectomy (MT) has become a standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Recent evidence suggests that general anesthesia (GA) and mechanical ventilation do not lead to inferior neurologic outcomes if compared to non-GA. However, the guidelines lack specific recommendations for ventilation targets during MT under GA. This systematic review aims to identify ventilation strategies correlating with better neurological outcomes in AIS patients undergoing MT, particularly focusing on oxygenation and carbon dioxide (CO2) targets. A systematic search of multiple databases was conducted to identify human studies reporting the correlation between ventilation strategies and neurological outcomes in MT for AIS. Eligible studies included clinical trials, observational studies, and case–control studies. Out of 157 studies assessed, 11 met the inclusion criteria. Five studies investigated oxygenation targets, while six studies explored CO2 targets. The published studies highlighted the controversial role of supplemental normobaric oxygen therapy and its potential association with worse outcomes. Regarding CO2 targets, the studies identified a potential association between end tidal CO2 levels and functional outcomes, with hypocapnia being unfavorable. This systematic review demonstrates that the current available evidence still lacks strength to suggest specific ventilation targets, but it highlights the potential risks of hyperoxia and hypocapnia in this specific cohort of patients

Oxygen targets and 6-month outcome after out of hospital cardiac arrest: a pre-planned sub-analysis of the targeted hypothermia versus targeted normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial

Background: Optimal oxygen targets in patients resuscitated after cardiac arrest are uncertain. The primary aim of this study was to describe the values of partial pressure of oxygen values (PaO2) and the episodes of hypoxemia and hyperoxemia occurring within the first 72 h of mechanical ventilation in out of hospital cardiac arrest (OHCA) patients. The secondary aim was to evaluate the association of PaO2 with patients' outcome. Methods: Preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after OHCA (TTM2) trial. Arterial blood gases values were collected from randomization every 4 h for the first 32 h, and then, every 8 h until day 3. Hypoxemia was defined as PaO2 300 mmHg. Mortality and poor neurological outcome (defined according to modified Rankin scale) were collected at 6 months. Results: 1418 patients were included in the analysis. The mean age was 64 ± 14 years, and 292 patients (20.6%) were female. 24.9% of patients had at least one episode of hypoxemia, and 7.6% of patients had at least one episode of severe hyperoxemia. Both hypoxemia and hyperoxemia were independently associated with 6-month mortality, but not with poor neurological outcome. The best cutoff point associated with 6-month mortality for hypoxemia was 69 mmHg (Risk Ratio, RR = 1.009, 95% CI 0.93-1.09), and for hyperoxemia was 195 mmHg (RR = 1.006, 95% CI 0.95-1.06). The time exposure, i.e., the area under the curve (PaO2-AUC), for hyperoxemia was significantly associated with mortality (p = 0.003). Conclusions: In OHCA patients, both hypoxemia and hyperoxemia are associated with 6-months mortality, with an effect mediated by the timing exposure to high values of oxygen. Precise titration of oxygen levels should be considered in this group of patients. Trial registration: clinicaltrials.gov NCT02908308 , Registered September 20, 2016. Keywords: Cardiac arrest; Hyperoxemia; Hypoxemia; Mortality; Neurological outcom

Sedation During Neurocritical Care

AbstractSedation is an essential therapeutic strategy in the care of neurocritical patients. Intravenous sedative agents are the most widely used, with promising alternatives (dexmedetomidine, ketamine, and volatile agents) to propofol and midazolam arising. Studies designed to evaluate superiority and avoid biases are required. A neurological awakening test is safe in most patients. Potential risks and benefits of limiting deep sedation and daily interruption of sedation in these patients remain unclear. The aim of this review was to report recent clinical evidence on sedation in this subgroup of patients, focusing on its effects on clinical prognosis

Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial

Purpose: The optimal ventilatory settings in patients after cardiac arrest and their association with outcome remain unclear. The aim of this study was to describe the ventilatory settings applied in the first 72 h of mechanical ventilation in patients after out-of-hospital cardiac arrest and their association with 6-month outcomes. Methods: Preplanned sub-analysis of the Target Temperature Management-2 trial. Clinical outcomes were mortality and functional status (assessed by the Modified Rankin Scale) 6 months after randomization. Results: A total of 1848 patients were included (mean age 64 [Standard Deviation, SD = 14] years). At 6 months, 950 (51%) patients were alive and 898 (49%) were dead. Median tidal volume (VT) was 7 (Interquartile range, IQR = 6.2-8.5) mL per Predicted Body Weight (PBW), positive end expiratory pressure (PEEP) was 7 (IQR = 5-9) cmH20, plateau pressure was 20 cmH20 (IQR = 17-23), driving pressure was 12 cmH20 (IQR = 10-15), mechanical power 16.2 J/min (IQR = 12.1-21.8), ventilatory ratio was 1.27 (IQR = 1.04-1.6), and respiratory rate was 17 breaths/minute (IQR = 14-20). Median partial pressure of oxygen was 87 mmHg (IQR = 75-105), and partial pressure of carbon dioxide was 40.5 mmHg (IQR = 36-45.7). Respiratory rate, driving pressure, and mechanical power were independently associated with 6-month mortality (omnibus p-values for their non-linear trajectories: p < 0.0001, p = 0.026, and p = 0.029, respectively). Respiratory rate and driving pressure were also independently associated with poor neurological outcome (odds ratio, OR = 1.035, 95% confidence interval, CI = 1.003-1.068, p = 0.030, and OR = 1.005, 95% CI = 1.001-1.036, p = 0.048). A composite formula calculated as [(4*driving pressure) + respiratory rate] was independently associated with mortality and poor neurological outcome. Conclusions: Protective ventilation strategies are commonly applied in patients after cardiac arrest. Ventilator settings in the first 72 h after hospital admission, in particular driving pressure and respiratory rate, may influence 6-month outcomes

Acute respiratory distress syndrome in traumatic brain injury: How do we manage it?

Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise

Genetic diversity, yield, and fruit quality of persimmon in the tropics

O objetivo deste trabalho foi estimar a diversidade genética, o rendimento e a qualidade de frutos de genótipos de caquizeiros cultivados nos trópicos, para selecionar materiais genéticos promissores. A extração de DNA foi realizada em folhas jovens de 19 genótipos de caqui. Para a caracterização pomológica, foram selecionados 15 genótipos. Para cada genótipo, 50 frutos foram colhidos pela manhã, no estágio de maturidade fisiológica, para determinar os seguintes parâmetros: características físico-químicas; e as variáveis produtivas número de frutos por planta, massa de matéria fresca média dos frutos, produtividade média e produtividade média estimada, em duas safras. Vinte marcadores SSR foram testados, dos quais 12 foram selecionados para avaliar a similaridade genética, o que permitiu a identificação de grupos distintos. O valor médio de diversidade genética encontrado foi 0,41, o que é indicativo de baixa diversidade entre os genótipos de caqui analisados. Os genótipos 'Guiombo', 'Iapar 125', 'Kakimel', 'Mikado RJ', 'Rama Forte Tardio' e 'Taubaté' apresentam alta produtividade. Os genótipos classificados como sendo de polinização constante adstringente ('Pomelo', 'Regina', 'Rubi' e 'Taubaté') e os classificados como sendo de polinização variante adstringente ('Rama Forte', 'Guiombo' e 'Cereja') são materiais com potencial para uso em programas de seleção e melhoramento genético, devido às suas excelentes características físico-químicas de fruta. A investigação por meio de marcadores moleculares é uma abordagem eficiente para estudar a diversidade genética de genótipos de caquizeiro cultivados nos trópicos.The objective of this work was to determine the genetic diversity, yield, and fruit quality of persimmon genotypes grown in the tropics, in order to select promising genetic materials. DNA extraction was performed on young leaves of 19 persimmon genotypes. For pomological characterization, 15 genotypes were selected. From each genotype, 50 fruit at the physiological maturity stage were harvested in the morning, in order to determine the following parameters: physicochemical characteristics; and the productive variables number of fruit per plant, average fruit fresh mass, average yield, and estimated average yield in two seasons. Twenty SSR markers were tested, out of which 12 were selected to evaluate genetic similarity, which allowed of the identification of distinct groups. The mean genetic diversity value found was 0.41, which is an indicative of low diversity among the analyzed persimmon genotypes. The 'Guiombo', 'Iapar 125', 'Kakimel', 'Mikado RJ', 'Rama Forte Tardio', and 'Taubaté' genotypes show a high yield. The genotypes classified as pollination-constant astringent ('Pomelo', 'Regina', 'Rubi', and 'Taubaté') and those classified as pollination-variant astringent ('Rama Forte', 'Guiombo', and 'Cereja') are potential materials for selection and genetic breeding programs due to their excellent fruit physicochemical characteristics. The investigation through molecular markers is an efficient approach to study the genetic diversity of persimmon genotypes grown in the tropics