Arterial Gas Emboli Secondary to Portal Venous Gas Diagnosed With Point-of-Care Ultrasound: Case Report and Literature Review.

BACKGROUND: Portal venous gas (PVG) is a rarely observed clinical finding generally associated with intestinal ischemia. The proper clinical response to the finding of PVG depends somewhat on the setting in which it is observed. Here we describe a case in which extensive arterial gas emboli (AGE) were encountered during point-of-care ultrasound (POCUS) and subsequent computed tomography (CT) identified PVG secondary to gastric wall ischemia as the likely source. CASE REPORT: A 69-year-old woman with history of metastatic colon cancer presented to the emergency department (ED) with altered mental status. On arrival, she was hypotensive, hypothermic, cachectic, and with abdominal distension. POCUS was performed to evaluate the source of the patient's hypotension, revealing the presence of PVG, as well as gas bubbles in all four chambers of the heart and the aorta. CT scan revealed gastric wall ischemia and confirmed the presence of significant air emboli throughout the portal venous system. Given the overall poor prognosis, the decision was made to forego further chemotherapy or surgery and the patient died later that week while under hospice care. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: AGE can occur in the setting of PVG. This may cause multi-organ failure by disrupting blood flow to organs, especially in patients with circulatory dysfunction, such as shock. Depending on the setting in which it is diagnosed, early detection of PVG may expedite earlier assessments of a patient's negative prognosis or initiation of attempted life-saving treatment. In this case report, we show that POCUS can be used to obtain an expedited diagnosis in a critically ill patient.

Ultrasound-guided foam sclerotherapy for chronic venous disease with ulcer. A prospective multiple outcome cohort study.

BACKGROUND: Chronic Venous Disease (CVD) is the main cause of chronic leg ulcers. Varicose veins are the most frequent cause of venous leg ulcers (VLU). 50.9% of Brazilian women have varicose veins and ulcer prevalence is as high as 4%. Ultrasound-guided foam sclerotherapy (UGFS) is a low-cost treatment option for varicose veins. OBJECTIVES: To analyze UGFS outcomes in patients with VLU. METHODS: Prospective consecutive single center cohort study. Patients with great saphenous vein (GSV) reflux and VLU were treated and followed-up for 180 days. The following were studied: quality of life (QoL), disease severity, healing, and elimination of GSV reflux. The Aberdeen questionnaire, a venous clinical severity score, and Duplex scanning (DS) results were analyzed. RESULTS: 22 patients aged 35 to 70 years were treated. There was improvement in quality of life, disease severity reduced, and ulcer diameter reduced (p < 0.001; ANOVA). 77.27% of VLU healed completely (95%CI: 59.76-94.78%). The dimensions of 20/22 VLU reduced (90.91%; 95%CI: 78.9-100%). GSV reflux was eliminated in 63.64% (95%CI: 43.54-83.74%). Men had greater QoL benefit and women had more complications. There were no severe complications. The VLU that had healed completely at the end of the study were smaller at baseline than those that did not completely heal. The GSV that were completely occluded at the end of the study were smaller at baseline than those that were not completely occluded (p < 0.05; Mann-Whitney). CONCLUSION: The results suggest that most patients benefited from UGFS.

CONTEXTO: A doença venosa crônica (DVC) é a principal causa de úlceras crônicas em membros inferiores. As varizes dos membros inferiores são a causa mais frequente de úlcera venosa (UV). No Brasil, 50,9% das mulheres têm varizes e a prevalência da úlcera chega a 4%. A escleroterapia ecoguiada com espuma (EEE) é uma alternativa de baixo custo para tratamento de varizes de membros inferiores. OBJETIVOS: Analisar evolução de portadores de UV tratados com EEE. MÉTODOS: Coorte prospectiva e consecutiva em um único serviço. Portadores de UV com veia safena magna (VSM) insuficiente foram acompanhados por 180 dias após EEE. Foram estudadas: qualidade de vida, gravidade da doença, cicatrização e eliminação do refluxo. Foram utilizados questionário Aberdeen, escore clínico venoso e ultrassom Doppler. RESULTADOS: Foram tratados 22 pacientes com idade entre 35 a 70 anos. Houve melhora na qualidade de vida, redução da gravidade da doença, e redução dos diâmetros das úlceras (p < 0.001; ANOVA). Houve redução das dimensões em 90,91% das úlceras [intervalo de confiança de 95% (IC95%) 78,9-100%], e cicatrização completa em 77,27% (IC95% 59,76-94,78%). O refluxo foi eliminado em 63,64% (IC95% 43,54-83,74%) das VSM. Homens tiveram maior benefício em qualidade de vida, e mulheres apresentaram mais complicações. Não houve complicações graves. As UV completamente cicatrizadas e as VSM que apresentaram oclusão completa apresentavam dimensões inicialmente menores quando comparadas às das UV não completamente cicatrizadas e das VSM não completamente ocluídas (p < 0,05; Mann-Whitney). CONCLUSÕES: Os resultados sugerem que EEE foi benéfica para a maioria dos pacientes.

Predictors of Nutritional Risk According to NRS-2002 and Calf Circumference in Hospitalized Older Adults with Neoplasms.

OBJECTIVES: To investigate nutritional markers that better predict nutritional risk according to the Nutritional Risk Screening (NRS-2002), to verify agreement between indicators, and to identify the calf circumference cut-off point for diagnosing nutritional risk. METHODS: Cross-sectional study with older patients hospitalized for neoplasms. The nutritional risk was assessed by NRS-2002 and the nutritional status by Subjective Global Assessment (SGA), Mini-Nutritional Assessment (MNA long form), calf circumference (CC), and body mass index (BMI). Statistical analyses included the chi-square and Mann-Whitney tests, Kappa coefficient, univariate and multiple logistic regression analyses to analyze the risk factors, and the receiver operator characteristic (ROC) curve to determine the cut-off point. RESULTS: The NRS-2002 and MNA had good agreement (k = 0.5281), but the NRS-2002 did not agree with the other nutritional indicators. According to regression analysis, the predictors of nutritional risk were the MNA (p = 0.0010, OR = 28.270); BMI (p = 0.0419, OR = 4.681), and age (p = 0.0021, OR = 1.309). The best CC cut-off point for predicting nutritional risk according to the NRS-2002 was ≤32.25 cm. CONCLUSION: Both the NRS-2002 and MNA are useful for the nutritional diagnosis of older adults hospitalized for neoplasms. When the MNA, BMI, and age are used together, they can better predict nutritional risk according to the NRS-2002.

Removal of total organic carbon from sewage wastewater using poly(ethylenimine)-functionalized magnetic nanoparticles.

The increased levels of organic carbon in sewage wastewater during recent years impose a great challenge to the existing wastewater treatment process (WWTP). Technological innovations are therefore sought that can reduce the release of organic carbon into lakes and seas. In the present study, magnetic nanoparticles (NPs) were synthesized, functionalized with poly(ethylenimine) (PEI), and characterized using TEM (transmission electron microscopy), X-ray diffraction (XRD), FTIR (Fourier transform infrared spectroscopy), CCS (confocal correlation spectroscopy), SICS (scattering interference correlation spectroscopy), magnetism studies, and thermogravimetric analysis (TGA). The removal of total organic carbon (TOC) and other contaminants using PEI-coated magnetic nanoparticles (PEI-NPs) was tested in wastewater obtained from the Hammarby Sjöstadsverk sewage plant, Sweden. The synthesized NPs were about 12 nm in diameter and showed a homogeneous particle size distribution in dispersion by TEM and CCS analyses, respectively. The magnetization curve reveals superparamagnetic behavior, and the NPs do not reach saturation because of surface anisotropy effects. A 50% reduction in TOC was obtained in 60 min when using 20 mg/L PEI-NPs in 0.5 L of wastewater. Along with TOC, other contaminants such as turbidity (89%), color (86%), total nitrogen (24%), and microbial content (90%) were also removed without significant changes in the mineral ion composition of wastewater. We conclude that the application of PEI-NPs has the potential to reduce the processing time, complexity, sludge production, and use of additional chemicals in the WWTP.

Determinants of malnutrition and post-operative complications in hospitalized surgical patients.

The study aimed to determine the nutritional status (NS) of hospitalized surgical patients and investigate a possible association between NS and type of disease, type of surgery and post-operative complications. The gender, age, disease, surgery, complications, length of hospital stay, number of medications, laboratory test results, and energy intake of 388 hospitalized surgical patients were recorded. NS was determined by classical anthropometry. The inclusion criteria were: nutritional status assessment done within the first 24 hours of admission, age ≥ 20 years, and complete medical history. Univariate and multiple Cox's regression analyses were employed to determine which variables were possible risk factors of malnutrition and complications. Malnutrition was more common in males (p=0.017), individuals aged 70 to 79 years (p=0.000), and individuals with neoplasms and digestive tract diseases (p=0.000). Malnourished individuals had longer hospital stays (p=0.013) and required more medications (p=0.001). The risk of malnutrition was associated with age and disease. Individuals aged 70 years or more had a two-fold increased risk of malnutrition (p=0.014; RR=2.207; 95% CI 1.169-4.165); those with neoplasms (p=0.008; RR=14.950; 95% CI 2.011-111.151) and those having digestive tract diseases (p=0.009; RR=14.826; 95% CI 1.939-113.362) had a 14-fold increased risk of malnutrition. Complications prevailed in older individuals (p=0.016), individuals with longer hospital stays (p=0.007), and individuals who died (p=0.002). The risk of complications was associated with age and BMI. In the present study, the risk of malnutrition was associated with age and type of disease; old age and low BMI may increase complications.

ADVANCED MEGAESOPHAGUS TREATMENT: WHICH TECHNIQUE OFFERS THE BEST RESULTS? A SYSTEMATIC REVIEW.

BACKGROUND: Advanced megaesophagus predisposes to risks of malnutrition infections and cancer, in addition to having a significant impact on quality of life. There is currently no consensus in the literature regarding the best surgical option for advanced megaesophagus, although there is a predilection for esophagectomy, despite this surgery being associated with significant morbidity and mortality. Other surgical procedures, such as esophageal mucosectomy and Heller cardiomyotomy, have been proposed with good results. AIMS: To conduct a systematic review and meta-analysis of the literature on the surgical treatment of advanced megaesophagus. METHODS: Databases used included PubMed, Latin American and Caribbean Health Sciences Literature (Lilacs), Embase and Medical Literature Analysis and Retrieval System Online (MedLine), as well as reference research. Two reviewers selected the articles independently. RESULTS: A total of 14 articles were chosen, which included 1,862 patients. The studies were divided into two groups: laparoscopic cardiomyotomy with fundoplication (213 patients) and major surgeries (1,649 patients). The studies yielded mostly good or excellent results regarding late outcomes in both groups. However, there was significant morbidity associated with the major surgeries group. CONCLUSIONS: Laparoscopic Heller myotomy can be performed on patients with advanced megaesophagus, with lower rates of complications and mortality compared to major surgeries, with reservations regarding late outcomes results.

SEX AND ASA CLASSIFICATION, NOT FASTING TIME, ARE ASSOCIATED WITH THE LIKELIHOOD OF COMPLICATIONS IN THE POSTOPERATIVE PERIOD.

BACKGROUND: According to the literature, some factors are associated with the development of postoperative complications including surgical approach, smoking, comorbidities, nutritional status, classification of the American Society of Anesthesiologists (ASA), fasting time period, and others. In the case of surgical patients, some factors are important for the assessment of the outcomes. AIMS: To investigate the factors associated with the likelihood of postoperative complications in surgical patients. METHODS: A prospective observational study was conducted with patients who were admitted to hospital more than 24 h. The following variables were investigated: nutritional risk screening, body mass index, ASA classification, fasting time, length of hospital stay, and postoperative complications. For statistical analysis, the Chi-square, Fisher's exact, and Mann-Whitney tests were used. To investigate the risk factors associated with postoperative complications, simple and multiple Cox regression analyses were used. RESULTS: In the total group of patients, there was an association between postoperative complications and men (p=0.0197), surgical risk (ASA) (p=0.0397) and length of hospital stay (p<0001); men showed a risk 2.2 times greater than women for some kind of postoperative complication (p=0.0456; PR=2.167; 95%CI 1.015-4.624). In patients undergoing gastrointestinal surgery, there was an association between postoperative complications and length of hospital stay (p<0001). In patients undergoing other surgeries, there was an association between postoperative complications and length of hospital stay (p<0001) and ASA classification (p=0.0160); ASA classification was considered a factor associated with the probability of postoperative complications (p=0.0335; PR=4.125; 95%CI 1.117-15.237). CONCLUSIONS: Men in the total group of patients and the ASA 3 or 4 criteria in the group of patients undergoing other surgeries were considered factors associated with the occurrence of complications in the postoperative period.

CoFe2O4 as a source of Co(II) ions for imidacloprid insecticide oxidation using peroxymonosulfate: Influence of process parameters and surface changes.

Nanometric cobalt magnetic ferrite (CoFe2O4) synthesized by distinct methods was used for in situ chemical activation of peroxymonosulfate (PMS) under neutral conditions to oxidize imidacloprid (IMD) insecticide. The effect of CoFe2O4 load (0.125-1.0 g L-1) and PMS concentration (250-1000 µM) was investigated as well as the influence of phosphate buffer and Co(II) ions. PMS activation by Co(II) ions, including those leached from CoFe2O4 (>50 µg L-1), exhibited a strong influence on IMD oxidation and, apparently, without substantial contributions from the solid phase. Within the prepared solid materials (i.e., using sol-gel and co-precipitation methods), high oxidation rates (ca. 0.5 min-1) of IMD were attained in ultrapure water. Phosphate buffer had no significant influence on the IMD oxidation rate and level, however, its use and solution pH have shown to be important parameters, since higher PMS consumption was observed in the presence of buffered solutions at pH 7. IMD byproducts resulting from hydroxylation reactions and rupture of the imidazolidine ring were detected by mass spectrometry. At optimum conditions (0.125 g L-1 of CoFe2O4 and 500 µM of PMS), the CoFe2O4 nanoparticles exhibited an increase in the charge transfer resistance and an enhancement in the surface hydroxylation after PMS activation, which led to radical (HO● and SO4●-) and nonradical (1O2) species. The latter specie led to high levels of IMD oxidation, even in a complex water matrix, such as simulated municipal wastewater at the expense of one-order decrease in the IMD oxidation rate.

Oxidation of imidacloprid insecticide through PMS activation using CuFe2O4 nanoparticles: Role of process parameters and surface modifications.

The contamination of water bodies by synthetic organic compounds coupled with climate change and the growing demand for water supply calls for new approaches to water management and treatment. To tackle the decontamination issue, the activation of peroxymonosulfate (PMS) using copper magnetic ferrite (CuMF) nanoparticles prepared under distinct synthesis conditions was assessed to oxidize imidacloprid (IMD) insecticide. After optimization of some operational variables, such as CuMF load (62.5-250 mg L-1), PMS concentration (250-1000 µM), and solution pH (3-10), IMD was completely oxidized in 2 h without interferences from leached metal ions. Such performance was also achieved when using tap water but was inhibited by a simulated municipal wastewater due to scavenging effects promoted by inorganic and organic species. Although there was evidence of the presence of sulfate radicals and singlet oxygen oxidizing species, only four intermediate compounds were detected by liquid chromatography coupled to mass spectrometry analysis, mainly due to hydroxyl addition reactions. Concerning the changes in surface properties of CuMF after use, no morphological or structural changes were observed except a small increase in the charge transfer resistance. Based on the changes of terminal surface groups, PMS activation occurred on Fe sites.

Lower 25-hydroxyvitamin D (25OHD) levels, diabetes and age are associated with foot and ankle fracture treatment complications.

Objective: This study investigated the nutritional status, 25-hydroxyvitamin D (25OHD), albumin and risk factors associated with complications in patients with foot and ankle fragility fractures. Subjects and methods: Prospective study, developed with patients who suffered fractures due to fragility of the foot and ankle (n = 108); the type of fractured bone, fracture mechanisms and classification were studied and also pseudoarthrosis, treatment, surgical dehiscence, anthropometry, 25OHD and albumin. The Chi-square or Fisher's exact test, Mann-Whitney and Kruskal-Wallis tests were used in the statistical analysis and the multiple logistic regression analysis was used to identify the risk factors associated with complications. Results: The factors that, together, were associated with treatment complications were the level of 25OHD (p = 0.0055; OR = 0.868 [1,152]; 95% CI = 0.786; 0.959 [1.043;1.272]) and diabetes (p = 0.0034; OR = 30,181; 95% CI = 3.087; 295.036). The factors that, together, were associated with the presence of any complication, were age (p = 0.0139; OR = 1.058; 95% CI = 1.011; 1,106) and 25OHD level (p = 0.0198; OR = 0.917; 95% CI = 0.852; 0.986). There was a complication probability above 0.40 associated with lower 25OHD levels (values below 20 ng/mL) and older age (over 50 years). Conclusion: Lower or abnormal levels of 25OHD were associated with pseudoarthrosis, and age and 25OHD were both risk factors for treatment complications in patients with foot and ankle fractures.

The Impact of Clinical and Craniofacial Changes on the Surgical Outcomes of Lateral Pharyngoplasty in the Treatment of Obstructive Sleep Apnea.

Objective To verify if maxillomandibular retrusion, obesity, and increased neck circumference are factors of worse surgical prognosis for lateral pharyngoplasty in apneic patients. Materials and Methods We evaluated 53 patients with obstructive sleep apnea who underwent lateral pharyngoplasty. Clinical evaluation was performed before the surgical procedure and included the measurement of body mass index (BMI) in kg/m 2 , neck circumference in centimeters, and a clinical evaluation of the facial profile obtained through the natural position of the oriented head. The polysomnographic evaluation was performed with at a minimum of 6 months after surgery, and polysomnographic results were correlated with the preoperative clinical data. Results The mean age of the patients was 38.8 years; the mean BMI was of 29.28kg/m 2 , and 84.9% of the sample was composed of men and 15.1% of women. There was a significant reduction in the mean value of the main respiratory parameters verified by polysomnography, such as apnea-hypopnea index (AHI) from 31.60 events per hour to 8.15 ( p < 0.001); NadirO 2 went from 81% to 85% ( p = 0.002) and mean oxyhemoglobin saturation from 94% to 95% ( p = 0.024). It was also observed that the greater the maxillomandibular retrusion, the lower the mean reduction of the AHI after surgery. The increase in neck circumference proved to be a factor associated with the surgical outcome, and for each 1-cm decrease in the neck circumference, the chance of surgical success increased 1.2-fold. Conclusion Lateral pharyngoplasty is an efficient surgical obstructive sleep apnea treatment. The lower the neck circumference measurement, the greater the chances of surgical success, and clinically evaluated maxillomandibular retrusion can reduce the magnitude of improvement in respiratory parameters after lateral pharyngoplasty in apneic patients.

Nutritional indicators' performance in malnutrition diagnosis of hospitalized elderly patients.

BACKGROUND: Several nutritional diagnosis methods and their relationship with clinical outcomes have been described. This study investigated malnutrition in hospitalized elderly patients (HEP) using different nutritional indicators and determined criteria to identify malnutrition and explore the variables that discriminate the risk of malnutrition. METHOD: Cross-sectional study with 500 HEP; different methods of nutritional diagnosis, their relationship with clinical outcomes and criteria for defining malnutrition were investigated. The GLIM criteria for the diagnosis of malnutrition was applied in this study. In the statistical analysis, the Chi-square test, Fisher's exact test, Mann-Whitney test, univariate and multiple logistic regression and the ROC curve were used. RESULTS: Patients aged 65-79 years, at nutritional risk or with malnutrition, had longer hospital stays (p = 0.0099; OR = 1.047; 95% CI = 1.011; 1.084) and lower body mass index (BMI) (p < 0.0001; OR = 0.867 (1153)); 95% CI = 0.813; 0.924 (1085; 1225). Patients aged ≥80 years had a lower BMI (p = 0.0053; OR = 0.779 (1284); 95% CI = 0.653; 0.928 (1078; 1531)). Accuracy was significant in both age groups for BMI (p < 0.0001; 65-79 years and p = 0.001; ≥80 years); for the lymphocyte count (p = 0.0167; 65-79 years and p = 0.0028; ≥80 years), and for the calf circumference (CC) (p < 0.0001; 65-79 years and p = 0.001; ≥80 years). Using the GLIM criteria, 27.78% of patients were considered malnourished. CC showed good accuracy, good specificity, but low sensitivity while BMI was more accurate to detect malnutrition in both age groups. CONCLUSION: CC showed good accuracy, good specificity, but low sensitivity to detect malnutrition. BMI was more accurate in both age groups to detect malnutrition.

Bibliometric analysis and conversion rate of abstracts presented at the Brazilian Congress of Coloproctology into publication of full articles.

INTRODUCTION: the presentation of research at a congress is an interesting means for scientific dissemination, but only with publication in an indexed journal does the data become accessible and disseminated. The conversion rate in published articles of abstracts presented at congresses is an indicator to assess the scientific quality of those events. The aim of this study is to evaluate bibliometric characteristics of abstracts presented at the Brazilian Congress of Coloproctology and to determine the factors that affect publication rates. METHODS: Retrospective evaluation of all abstracts presented at the Brazilian Congresses of Coloproctology from 2015 to 2019. Multiple databases were analyzed to estimate the conversion rate of the presented papers, as well as variables associated with the conversion of abstracts into full manuscripts through bivariate analysis and multivariate variables of these predictors. RESULTS: 1756 abstracts were analyzed. Most studies are retrospective, series or case reports, and even personal experience. The conversion rate was 6.9%. The presence of statistical analysis was twice as high for published abstracts as for unpublished ones. CONCLUSION: the data presented demonstrate a low scientific productivity of the specialty, since the research carried out is, for the most part, not published as complete manuscripts. The predictors of publication of abstracts were: multicenter studies, studies with statistical analysis, study designs with a higher level of evidence and studies awarded by the congress.

IS CALF CIRCUMFERENCE ASSOCIATED WITH CLINICAL AND NUTRITIONAL OUTCOME IN OLDER PATIENTS?

BACKGROUND: Previous studies have shown a relationship between calf circumference (CC) and outcomes in hospitalized patients. AIMS: To investigate the relationship between CC and clinical and nutritional outcomes in older in-patients (OiP) in a surgery ward. METHODS: This was a cross-sectional study with 417 OiP in a surgery ward. Clinical variables, anthropometry, and nutritional screening instruments such as subjective global assessment (SGA), mini nutritional assessment (MNA), and nutritional risk screening (NRS) were used in the investigation. The tests Pearson's chi-square, Mann-Whitney, Kruskal-Wallis, and Spearman's coefficient, and multiple linear regression analyses were used to review the factors associated with CC. RESULTS: Lower CC values were found in the age group 80 years and over (p<0.0001), presence of complications (p=0.0269), NRS (p<0.0001), SGA (p<0.0001), and MNA (p<0.0001). Gender (p=0.0011; partial R2=0.01151), age (p=0.0002; partial R2=0.06032), body mass index (p≤0.0001; partial R2=0.40820), and arm circumference (p≤0.0001; partial R2=0.11890) are variables that together were associated with CC. There was also a relationship between SGA (p=0.0166; partial R2=0.00605) and absence of complications during hospitalization (p=0.0047; R2=0.01154) with CC. CONCLUSIONS: Gender, age, body mass index, and arm circumference were jointly associated with CC, in addition to SGA and absence of complications. The CC is a relevant indicator for OiP in the clinical practice.

Involvement of methicillin-susceptible Staphylococcus aureus related to sequence type 25 and harboring pvl genes in a case of carotid cavernous fistula after community-associated sepsis.

Staphylococcus aureus encoding Panton-Valentine leukocidin (PVL) genes has become the cause of life-threatening infections. We describe a case of carotid cavernous fistula after bacteremia in a 12-year-old male, caused by a methicillin-susceptible S. aureus isolate carrying the pvl, fnbA, and ebpS genes and related to sequence type 25 (ST25). The patient's condition was complicated by pleural empyema and osteomyelitis in the right femur. The patient was discharged in good clinical condition after 160 days of hospitalization.

Endoluminal dilation technique to remove "stuck" tunneled hemodialysis catheters.

Most tunneled catheters can be easily removed after the retention cuff is dissected. Occasionally, these catheters can become resistant to removal even after application of potentially hazardous forceful traction. In addition, an infected catheter may cause life-threatening septicemia. Several methods have been described for their extraction, some of which may be available only in tertiary-care facilities. The present report describes the successful extraction of five such "stuck" catheters by using a recently described technique of endoluminal dilation. The technique appears safe and straightforward and can be performed in any interventional suite while allowing preservation of venous access.

The end-of-life care practices of emergency care nurses and the factors that influence these practices: An integrative review.

INTRODUCTION: Due to philosophical tensions between end-of-life care and emergency care, nurses in the emergency department face challenges in the provision of end-of-life care. The purpose of this integrative review was to synthesise evidence of the end-of-life care practices of emergency care nurses and the factors that influence these practices. METHODS: For this integrative review, CINAHL, Embase, and MEDLINE databases were systematically searched in April 2020. In total, 30 studies written in English and published between 2010 and 2020 investigating the experiences of nurses caring for a patient that died in the emergency department were included. A constant comparative method was used to analyse and synthesise data. RESULTS: End-of-life care practices prominent in the literature included modifying the environment for privacy, the provision of information to families and the management of symptoms. The culture of emergency care, the nurse's personal characteristics, the trajectory of death and available resources are factors that appear to determine whether ED nurses immerse themselves in end-of-life care or display distancing behaviours. CONCLUSION: There is limited evidence articulating the frequency to which specific practices are undertaken and the magnitude to which various factors influence end-oflife care provision. The generation of such knowledge may facilitate the development of initiatives that can optimise end-of-life care in the emergency department.

End-of-life care in emergency departments: A national cross-sectional survey of emergency care nurses.

BACKGROUND: An ageing population and increasing chronicity of illness will likely contribute to increasing presentations to the emergency department (ED) by patients at the end-of-life (EOL). This study aimed to identify the self-reported EOL care practices of emergency care nurses and the factors influencing EOL care. METHODS: An online survey was distributed to Australian emergency care nurses in August, 2020. Statistical analyses were undertaken to identify the most frequently undertaken EOL practices and factors influencing practice. RESULTS: There were 178 responses to the survey (response rate 11.3%). The most frequently reported EOL practices were environmental modification (M=4.4/5, SD=0.4) and information sharing practices (M=4.4/5, SD=0.4). Emotional support practices were the least frequently reported practices by emergency care nurses (M=3.6/5, SD=0.9). Participants reported a lack of resources (M=2.4/5, SD=0.8) and opportunities to gain end-of-life care knowledge (M=2.9/5, SD=0.9). However, a generally positive attitude towards EOL care was indicated as participants reported strong agreement to palliative values (M=4.6/5, SD=0.4). CONCLUSIONS: Results of this study suggest that most frequently reported EOL care practices of emergency care nurses require the least emotional engagement. The findings can inform areas of knowledge development and resources for emergency care nurses.

Prognostic analysis of lymph node ratio of patients with disease recurrence previously submitted to cervical dissection surgery for head and neck cancer.

INTRODUCTION: the variable lymph node ratio has recently been studied as a possible influencer in the survival of patients diagnosed with head and neck cancer. OBJECTIVE: to analyze the correlation between lymph node density and survival of recurred disease patients previously submitted to cervical dissection surgery due to head and neck squamous cell carcinoma. METHOD: we retrospectively analyzed 71 medical records of patients treated at the Head and Neck Surgery Service of the Pontifícia Universidade Católica de Campinas who had undergone cervical dissection surgery and presented tumor recurrence between 2006 and 2019. Patient and tumor data such as age, gender, skin color, smoking, alcohol consumption, location of the primary tumor, anatomopathological characteristics and lymph node status were correlated with the survival time. RESULTS: we found a predominance of males and the mean age was 59.5 years. The most frequent primary site was the oral cavity followed by the larynx and oropharynx. The mortality rate was 53.52% and the mean lymph node ratio 0.28. We found influence on survival with statistical significance for the parameters: lymph node ratio, number of dissected and affected lymph nodes, T and N staging, type of treatment proposed (palliative or surgical), presence of compromited margins in the primary tumor and lymph node extravasation. CONCLUSION: the calculation of lymph node density in patients with recurred disease after cervical dissection surgery by head and neck squamous cell carcinoma should be taken into account during therapeutic planning and prognostic evaluation due to its direct influence on the survival.