Alguns desenvolvimentos actuais em Ergonomia

Inexistent

Ethical Criteria for the Admission and Management of Patients in the ICU Under Conditions of Limited Medical Resources: A Shared International Proposal in View of the COVID-19 Pandemic

Introduction The present pandemic has exposed us to unprecedented challenges that need to be addressed not just for the current state, but also for possible future similar occurrences. It is worth pointing out that discussions on the allocation of medical resources may not necessarily refer to an exception, but, unfortunately, to a regular condition for a large part of humanity (1). The criteria for admission to an Intensive Care Unit (ICU) setting generally take into account multiple factors. There must be a diagnostic and prognostic basis for the decisions made, considering both biological factors and patient values and wishes. Furthermore, the decision-making process should, whenever possible, respect the patient's advance directives as well as the relationship with the patient's family or attorney. Therapeutic neglect should be avoided. Having applied standard clinical evaluation criteria for the appropriate treatment of patients with COVID-19, including consideration of prognosis, if a hospital then finds itself unable to provide optimal treatment (e.g., due to a disproportion between the number of patients and the availability of beds, healthcare providers, ventilators, and drugs in the ICU), it becomes necessary to evaluate, case by case, how to achieve justice and the best possible good for the greatest number of patients. It is therefore mandatory to explore alternative solutions; these include increasing available beds and healthcare providers, implementing alternative, though suboptimal, approaches (where appropriate), transferring patients to other clinical units, etc. Making these decisions properly also involves the recovery of the political role of medicine and science (2). If the imbalance between needs and resources reaches a critical level, an emergency triage protocol, following the operational and ethical indications of “disaster medicine,” should be activated. These have been deployed in major and serious natural (earthquakes or tsunamis for example) and technological (factory explosions, public transport accidents for example) disasters, as well as following terrorist attacks (3, 4). The question of the feasibility of developing a clinical evaluation algorithm to support the decision-making of the triage team remains open, though many such protocols have been written. According to the above, we propose the following five ethical criteria for the triage of patients in conditions of limited resources, such as the COVID pandemic. They are the result of an interdisciplinary and intercultural dialogue between specialists from different disciplines. Several of the authors are working in the main epicenters of the crisis and currently are playing a central role in the bioethical, clinical, social and legal aspects of the management of the COVID-19 pandemic

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Alarm initiated activities: matching visual formats to alarm handling 'tasks'

This paper addresses the selection of visual alarm formats for different 'alarm initiated activities'. The activities under examination were alarm handling tasks. Seven such tasks have been identified, namely: observe, accept, analyse, investigate, correct, monitor and reset. One of the most important stages is the initial analysis of the alarm information as this determines the subsequent manner in which the information is processed. It was hypothesised that the format in which the information is presented will determine the success of the alarm handling task, hence the proposal to match formats to tasks. The findings suggest that text-based formats are best suited to tasks requiring time-based reasoning, mimic formats are best suited to tasks requiring spatial location and annunciator formats are best suited to tasks requiring recognition of spatial patterns. The importance of considering both reaction time and accuracy of response in consideration of task match was also noted. In summary, it is suggested that care needs to be taken to determine the appropriateness of the medium for any given task and the demands it places on the human operato

PTH-32 development of a novel electronic referral grading & triage system

Introduction: prior to Covid-19, demand for secondary care appointments continued to rise year on year suggesting unsustainable future post-pandemic demand. Now is thus the right time to invest in triage and clinical pathway innovation.Methods: anew fully-integrated digital triage system was built at our institution allowing for document upload and electronic triage. Data pertaining to referral time, triage decision, outpatient appointments and direct-to-test was extracted from the backend to plot empirical cumulative distribution functions, interquartile ranges and allow statistical comparison using the Kruskal-Wallis’ test.Results: we analysed the first 704 luminal Gastroenterology referrals through the new triage system with the following sub-specialty classifications: Iron deficiency anaemia (IDA) – 200, Upper gastrointestinal symptoms (UGI) – 152, Inflammatory bowel disease (IBD) – 116, Irritable bowel syndrome (IBS/Functional) – 95, Lower gastrointestinal symptoms/change in bowel habit alone (LGI/CIBH) – 59, Coeliac – 27, Surgical – 25, Complex Functional – 12, Intestinal failure (IF/Nutrition) – 12, Hepatology – 4. 664 (95%) of referrals were accepted with 179 (27%) being sent direct to test. Of these only 42 (23.5%) had a subsequent clinic appointment booked, vs 436 (90%) for those not going direct to test. In addition, sending patients direct to test increased the proportion of subsequent routine clinic appointments from 55% to 70%. Median timelag from referral to grading was four days with grading taking a single day and appointments occurring 17 days later on average. Direct-to-test was most common amongst patients in the UGI (52.6%) and IBD (50%) sub-cohorts. This was significantly different vs other groups at the (p<0.05) level. [PTH-32 Figure 1 Subspecialty Referrals vs Direct-To-Test Numbers not included].Conclusions: using a system as described here substantially improves data capture and efficiency. Direct to test reduces both need for clinic appointments and the urgency of subsequent appointments. IBD and UGI are the subspecialties most likely to benefit from direct to test approaches. IDA could be another suitable specialty and the plan is to address this in the future

Optimisation of COVID‐19 diagnostic pathways in acute hospital admissions to prevent nosocomial transmission

Introduction: In the management of acute hospital admissions during the COVID-19 pandemic, safe patient cohorting depends on robust admission diagnostic strategies. It is essential that screening strategies are sensitive and rapid, to prevent nosocomial transmission of COVID-19 and maintain patient flow. Methods: We retrospectively identified all COVID-19 positive and suspected cases at our institution screened by reverse transcription polymerase chain reaction (RT-PCR) between 4 April and 28 June 2020. Using RT-PCR positivity within 7 days as our reference standard, we assessed sensitivity and net-benefit of three admission screening strategies: single admission RT-PCR, composite admission RT-PCR and CXR and repeat RT-PCR with 48 h. Results: RT-PCR single-test sensitivity was 91.5% (87.8%-94.4%) versus 97.7% (95.4%-99.1%) (p = 0.025) for RT-PCR/CXR composite testing and 95.1% (92.1%-97.2%) (p = 0.03) for repeated RT-PCR. Net-benefit was 0.83 for single RT-PCR versus 0.89 for RT-PCR/CXR and 0.87 for repeated RT-PCR at 0.02% threshold probability. Conclusion: The RT-PCR/CXR composite testing strategy was highly sensitive when screening patients at the point of hospital admission. Real-world sensitivity of this approach was comparable to repeat RT-PCR testing within 48 h; however, faster facilitating improved patient flow

Routine molecular point-of-care testing for SARS-CoV-2 reduces hospital-acquired COVID-19

Objectives: Risk of hospital-acquired COVID-19 (HA-COVID-19) infection is increased by cohorting infected and non-infected patients together in assessment areas, whist awaiting laboratory PCR results. Molecular point-of-care tests (mPOCT) reduce time to results and improve patient flow but the impact on HA-COVID-19 is unknown. Methods: In this pre and post implementation study patients were evaluated across two time periods: March 1st to August 13th 2020, prior to the introduction of mPOCT in medical admissions areas, and 14th August 2020 to 1st April 2021, after mPOCT introduction. The primary outcome was proportion of HA-COVID-19 infection among all COVID-19 positive patients. Secondary outcome measures included time to SARS-CoV-2 results, length of time spent in the medical assessment area and comparison of local, regional and national proportions of HA-COVID-19. Results: 1988 patients were admitted through the acute medicine admission cohorting area and tested for SARS-CoV-2 prior to introducing mPOCT and 4640 afterwards. Median (IQR) time to SARS-CoV-2 result was 6.5 (2.1–17.9) hours prior to introducing mPOCT and 1.0 (0.8–1.3) hours afterwards (p &lt; 0.0001). Median (IQR) duration in the assessment cohort area was 12.0 (4.8–20.6) hours prior to introduction of POCT and 3.2 (2.0–5.6) hours afterwards (p &lt; 0.0001). The proportion of hospital-acquired COVID-19 cases was 108 (16.5%) of 654 prior to introducing mPOCT compared with 168 (9.4%) of 1782 afterwards, (HR 0.55, 95%CI 0.43–0.70; p &lt; 0.0001). In the period following the introduction of mPOCT up to 1st April 2021 the median proportion of HA-COVID-19 was 13.6% (95%CI 8.2–18.9%) locally, compared with 43.8% (95%CI 37.8–49.9%) for all acute NHS trusts regionally and 30.9% (95%CI 28.4–33.5%) for all NHS trusts nationally. Conclusions: Routine mPOCT for SARS-CoV-2 was associated with reduced time to results, time spent in admission cohort areas, and hospital-acquired COVID-19, compared to laboratory PCR.</p