Approach, management and prediction of prognosis in the acute abdomen syndrome in dogs. Study of prognosis predictors in 28 cases

Dissertação de Mestrado Integrado em Medicina VeterináriaThe acute abdomen syndrome is characterized by an acute onset of abdominal pain, usually associated with general signs such as vomiting, diarrhoea, postural and gait changes, anorexia, lethargy and shock. Success results from a proactive approach to management, including rapid stabilization of major body systems, early identification of the inciting problem(s), attention to comorbid conditions, and timely definitive therapy. Herewith comes decision making, whether to take a patient to surgery or manage the patient medically. A thorough and systematic approach requires the use of diagnostic imaging modalities, including radiology and ultrasonography, performing diagnostic peritoneal lavage or abdominal paracentesis techniques, and blood work evaluation, including complete blood count and biochemistry profiles. In some cases, the results of diagnostic tests may lead to surgical versus medical management, particularly when a patient fails to respond to medical management alone. In other cases, rapid surgical management is necessary for patient survival. Also it must take into account the capabilities and equipment of the clinic, as well as the staff skills. This may be extremely effortful, time-consuming and expensive so the owners must be informed about the prognosis for survival as they frequently face the dilemma of euthanasia. In an attempt to make more valid prognostic assessment in cases of acute abdomen syndrome, many individual predictive factors and univariable analysis where investigated. A retrospective study was carried out on 28 dogs presented with acute abdomen. Medical records were reviewed and information regarding dog signalment, history, clinical and laboratory data, surgical findings and outcome was collected. After analysis, several easily measurable parameters were found to be outcome predictors in dogs with acute abdomen, these being creatinine and alkaline phosphatase values, skin tent evaluation and dehydration.RESUMO - ABORDAGEM, MANEIO E PREVISÃO DE PROGNÓSTICO NA SÍNDROME DE ABDÓMEN AGUDO EM CÃES. ESTUDO DE PREVISORES DE PROGNÓSTICO EM 28 CASOS - A síndrome de abdómen agudo é caracterizada por dor abdominal de início repentino, normalmente associada a sinais clínicos gerais tais como vómito, diarreia, alterações de postura e equilíbrio, anorexia, letargia e choque. O sucesso na resolução desta síndrome resulta de uma abordagem proactiva ao maneio médico, incluindo estabilização rápida dos sistemas vitais, rápida identificação, atenção a situações concomitantes e terapia definitiva realizada atempadamente. Posto isto, a decisão de submeter o paciente a cirurgia ou de o tratar conservativamente tem de ser tomada. Uma abordagem completa e sistemática passa pela imagiologia, incluindo raio-x e ecografia, lavagem peritoneal diagnóstica ou abdominocentese, e análises sanguíneas, incluindo hemograma e bioquímicas. Por vezes, os resultados dos testes diagnósticos podem levar ao maneio médico versus o cirúrgico, especialmente quando não há resposta à terapêutica conservativa por parte do paciente. Noutros casos, o maneio cirúrgico urgente é necessário para a sobrevivência do doente. É também necessário ter em consideração as capacidades e equipamento do centro de atendimento médico veterinário, bem como as competências dos veterinários responsáveis. Isto pode ser extremamente trabalhoso, demorado e caro para os proprietários, devendo estes ser informados acerca do prognóstico, visto que muitas das vezes deparam-se com o dilema da eutanásia. Na tentativa de tornar a avaliação prognóstica mais eficaz na síndrome de abdómen agudo, foram avaliados previsores individuais de prognóstico e realizada a respetiva análise univariada. Foi realizado um estudo retrospectivo em 28 cães que se apresentaram com abdómen agudo. A anamnese foi feita e a informação sobre os sinais clínicos, os dados do exame físico e laboratoriais, os achados das cirurgias e prognóstico foram colhidos. Após análise, alguns parâmetros facilmente mensuráveis, mostraram contribuir para a previsão do prognóstico em cães com abdómen agudo, sendo estes os valores de creatinina e fosfatase alcalina, a avaliação da prega de pele e a desidratação do animal

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Characterisation of microbial attack on archaeological bone

As part of an EU funded project to investigate the factors influencing bone preservation in the archaeological record, more than 250 bones from 41 archaeological sites in five countries spanning four climatic regions were studied for diagenetic alteration. Sites were selected to cover a range of environmental conditions and archaeological contexts. Microscopic and physical (mercury intrusion porosimetry) analyses of these bones revealed that the majority (68%) had suffered microbial attack. Furthermore, significant differences were found between animal and human bone in both the state of preservation and the type of microbial attack present. These differences in preservation might result from differences in early taphonomy of the bones. © 2003 Elsevier Science Ltd. All rights reserved

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.13Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Thrombotic and hemorrhagic complications of COVID-19 in adults hospitalized in high-income countries compared with those in adults hospitalized in low- and middle-income countries in an international registry

Background: COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HICs). Objectives: The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries [LMICs]) with those in HICs, delineate the frequency across a range of treatment levels, and determine associations with in-hospital mortality. Methods: Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020, and September 15, 2021, met inclusion criteria, including admission to a hospital for laboratory-confirmed, acute COVID-19 and data on complications and survival. The advanced-treatment cohort received care, such as admission to the intensive care unit, mechanical ventilation, or inotropes or vasopressors; the basic-treatment cohort did not receive any of these interventions. Results: The study population included 495,682 patients from 52 countries, with 63% from LMICs and 85% in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76%-3.4%) than in LMICs (0.09%-1.22%). Complications were more frequent in the advanced-treatment cohort than in the basic-treatment cohort. Coagulopathy complications were associated with increased in-hospital mortality (odds ratio, 1.58; 95% CI, 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, the mortality was higher among patients in LMICs than among patients in HICs (odds ratio, 1.45; 95% CI, 1.39-1.51). Conclusion: In a large, international registry of patients hospitalized for COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of a greater magnitude among patients in LMICs. Additional research is needed regarding timely diagnosis of and intervention for coagulation derangements associated with COVID-19, particularly for limited-resource settings

The value of open-source clinical science in pandemic response: lessons from ISARIC

International audienc