O USO DE BIOESTIMULADORES INJETÁVEIS DE COLÁGENO PARA CONTROLE DE SINAIS DE ENVELHECIMENTO FACIAL

O envelhecimento facial é um processo multifatorial, composto por fatores extrínsecos e intrínsecos. No tocante aos aspectos extrínsecos, estes englobam sobretudo os danos gerados pela exposição ao sol, em contrapartida os elementos intrínsecos incluem: características individuais em relação a genética, alterações hormonais e produção de espécies reativas de oxigênio. O envelhecimento da pele é, portanto, fisiológico e inevitável, apresentando um impacto negativo na autoestima das pessoas, cenário que corrobora para a maximização da procura por tratamentos de controle e de prevenção dos sinais de longevidade. Diante disso, a dúvida central do estudo foi definida como: Quais são os principais bioestimuladores injetáveis de colágeno para o controle de sinais de envelhecimento facial? Este artigo apresenta como objetivo fundamental relatar os tipos de bioestimuladores injetáveis de colágeno e os seus principais resultados estéticos. A metodologia da pesquisa trata-se de uma revisão bibliográfica do tipo integrativa, apresentando aspecto qualitativo e objetivo descritivo. As bases de dados usadas foram: PubMed, MEDLINE e LILACS, na qual foram selecionados 17 artigos. Em relação aos resultados, os estudos avaliados mostraram que a utilização de bioestimuladores de colágeno como o poli-L-lático, a policaprolactona e a hidroxiapatita de cálcio proporcionaram rejuvenescimento facial e corporal da pele, garantindo melhora do fortalecimento, da espessura e elasticidade, minimizando rugas e flacidez. Por fim, os procedimentos não invasivos listados, embora demonstrem resultados estéticos importantes, não possuem efeito permanente, necessitando de aplicações e tratamentos futuros para a sua manutenção. Facial aging is a multifactorial process, composed of extrinsic and intrinsic factors. Regarding the extrinsic aspects, these encompass mainly the damage generated by sun exposure, whereas the intrinsic elements include: individual characteristics in relation to genetics, hormonal changes and production of reactive oxygen species. Skin aging is, therefore, physiological and inevitable, having a negative impact on people's self-esteem, a scenario that corroborates the maximization of the search for treatments to control and prevent longevity signs. Therefore, the central question of the study was defined as: What are the main injectable collagen biostimulators for the control of facial aging signs? The fundamental objective of this article is to report on the types of collagen biostimulators and their main aesthetic results. The methodology of the research is an integrative literature review, with a qualitative aspect and descriptive objective. The databases used were PubMed, MEDLINE and LILACS, from which 17 articles were selected. In relation to the results, the studies evaluated showed that the use of collagen biostimulators such as poly-L-lactic, polycaprolactone and calcium hydroxyapatite provided facial and body skin rejuvenation, ensuring improvement in strength, thickness and elasticity, minimizing wrinkles and sagging. Finally, the non-invasive procedures listed, although they demonstrate important aesthetic results, do not have a permanent effect, requiring future applications and treatments for their maintenance. El envejecimiento facial es un proceso multifactorial, compuesto por factores extrínsecos e intrínsecos. Con respecto a los aspectos extrínsecos, éstos abarcan principalmente el daño generado por la exposición solar, mientras que los elementos intrínsecos incluyen: características individuales en relación con la genética, cambios hormonales y producción de especies reactivas de oxígeno. El envejecimiento de la piel es, por lo tanto, fisiológico e inevitable, con un impacto negativo en la autoestima de las personas, escenario que corrobora la maximización de la búsqueda de tratamientos para controlar y prevenir los signos de longevidad. Por lo tanto, la pregunta central del estudio fue definida como: ¿Cuáles son los principales bioestimuladores inyectables de colágeno para el control de los signos de envejecimiento facial? El objetivo fundamental de este artículo es informar sobre los tipos de bioestimuladores inyectables de colágeno y sus principales resultados estéticos. La metodología de la investigación es una revisión bibliográfica integradora, con un aspecto cualitativo y objetivo descriptivo. Las bases de datos utilizadas fueron: PubMed, MEDLINE y LILACS, de las cuales fueron seleccionados 17 artículos. En cuanto a los resultados, los estudios evaluados mostraron que el uso de bioestimuladores de colágeno como poli-L-láctico, policaprolactona e hidroxiapatita de calcio proporcionaron rejuvenecimiento de la piel facial y corporal, garantizando mejoría en el fortalecimiento, espesor y elasticidad, minimizando arrugas y flacidez.Finalmente, los procedimientos no invasivos enumerados, aunque demuestran importantes resultados estéticos, no tienen un efecto permanente, requiriendo futuras aplicaciones y tratamientos para su mantenimiento. O envelhecimento facial é um processo multifatorial, composto por fatores extrínsecos e intrínsecos. No tocante aos aspectos extrínsecos, estes englobam sobretudo os danos gerados pela exposição ao sol, em contrapartida os elementos intrínsecos incluem: características individuais em relação a genética, alterações hormonais e produção de espécies reativas de oxigênio. O envelhecimento da pele é, portanto, fisiológico e inevitável, apresentando um impacto negativo na autoestima das pessoas, cenário que corrobora para a maximização da procura por tratamentos de controle e de prevenção dos sinais de longevidade. Diante disso, a dúvida central do estudo foi definida como: Quais são os principais bioestimuladores injetáveis de colágeno para o controle de sinais de envelhecimento facial? Este artigo apresenta como objetivo fundamental relatar os tipos de bioestimuladores injetáveis de colágeno e os seus principais resultados estéticos. A metodologia da pesquisa trata-se de uma revisão bibliográfica do tipo integrativa, apresentando aspecto qualitativo e objetivo descritivo. As bases de dados usadas foram: PubMed, MEDLINE e LILACS, na qual foram selecionados 17 artigos. Em relação aos resultados, os estudos avaliados mostraram que a utilização de bioestimuladores de colágeno como o poli-L-lático, a policaprolactona e a hidroxiapatita de cálcio proporcionaram rejuvenescimento facial e corporal da pele, garantindo melhora do fortalecimento, da espessura e elasticidade, minimizando rugas e flacidez. Por fim, os procedimentos não invasivos listados, embora demonstrem resultados estéticos importantes, não possuem efeito permanente, necessitando de aplicações e tratamentos futuros para a sua manutenção.

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

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

Guidelines for the use and interpretation of assays for monitoring autophagy (4th edition)1.

In 2008, we published the first set of guidelines for standardizing research in autophagy. Since then, this topic has received increasing attention, and many scientists have entered the field. Our knowledge base and relevant new technologies have also been expanding. Thus, it is important to formulate on a regular basis updated guidelines for monitoring autophagy in different organisms. Despite numerous reviews, there continues to be confusion regarding acceptable methods to evaluate autophagy, especially in multicellular eukaryotes. Here, we present a set of guidelines for investigators to select and interpret methods to examine autophagy and related processes, and for reviewers to provide realistic and reasonable critiques of reports that are focused on these processes. These guidelines are not meant to be a dogmatic set of rules, because the appropriateness of any assay largely depends on the question being asked and the system being used. Moreover, no individual assay is perfect for every situation, calling for the use of multiple techniques to properly monitor autophagy in each experimental setting. Finally, several core components of the autophagy machinery have been implicated in distinct autophagic processes (canonical and noncanonical autophagy), implying that genetic approaches to block autophagy should rely on targeting two or more autophagy-related genes that ideally participate in distinct steps of the pathway. Along similar lines, because multiple proteins involved in autophagy also regulate other cellular pathways including apoptosis, not all of them can be used as a specific marker for bona fide autophagic responses. Here, we critically discuss current methods of assessing autophagy and the information they can, or cannot, provide. Our ultimate goal is to encourage intellectual and technical innovation in the field

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

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit