A Hemodynamic Echocardiographic Evaluation Predicts Prolonged Mechanical Ventilation in Septic Patients: A Pilot Study.

Prolonged mechanical ventilation (PMV) is common among critically ill septic patients and leads to serious adverse effects. Transthoracic echocardiography (TTE) is an efficient tool for the assessment of septic shock. Our study investigated the relationship between TTE parameters and PMV in mechanically ventilated septic shock patients. TTE was performed in the first 24 h of intensive care unit admission, acquiring data on cardiac output (CO), cardiac index (CI), s' wave (s'), E wave (E), e' wave (e') and E/e' ratio. We compared data on patients who met the criteria for PMV with data on patients who did not. Sixty-four patients were included, 26 of whom met the criteria for PMV. CO, CI and s' were higher in patients who required PMV (5.49 vs. 4.20, p = 0.02; 2.95 vs. 2.34, p = 0.04; and 12.56 vs. 9.81, p = 0.01, respectively). CI correlated with s' (r = 0.37, p < 0.01). The areas under the receiver operating characteristic curves for CO, CI and s' in assessing the need for PMV were, respectively, 0.7 (fair results), 0.69 and 0.68 (poor results). Despite a lack of a prognostic model, the observed differences suggest that hemodynamic TTE could provide information on the risk of PMV in septic shock.

Implementation and Assessment of Lung Ultrasound Training Curriculum for Physiotherapists With a Focus on Image Acquisition and Calculation of an Aeration Score.

Described here is the implementation of a lung ultrasound course for physiotherapists focused on the acquisition and retention of knowledge and skills. Initially, we provided online lectures in a virtual learning environment (VLE), in which we taught the semiquantification of edema through a lung ultrasound score (LUS). Afterward, the physiotherapists participated in face-to-face lectures (which resumed the online lectures), followed by hands-on training and simulation with ultrasound. We assessed knowledge acquisition through a multiple-choice test with 30 questions (totaling 10 points). The test was applied before accessing the VLE (pre-VLE), before the face-to-face course and at its end (pre- and post-course). Physiotherapists collected actual patients' ultrasound scans, which were uploaded to the VLE and assessed by three supervisors, who performed a consensus LUS calculation and gave virtual written feedback. Thirteen physiotherapists collected 59 exams. The test results were 3.60 ± 1.58 (pre-VLE), 5.94 ± 1.45 (pre-course) and 8.50 ± 0.71 (post-course), with p < 0.001 for all. The intraclass correlation coefficient for LUS between physiotherapists and supervisors was 0.814 (p < 0.001), with moderate-to-weak agreement for LUS of the lung apical, median and basal zones, with κ = 0.455.334, and 0.417 (p < 0.001 for all). Trainees were found to have increased short-term acquisition and retention of knowledge and skills, with a good intraclass correlation coefficient between them and the consensus of supervisors for the LUS of actual patients.

Reduced physical functional performance before hospitalization predicts life support limitations and mortality in nonsurgical intensive care unit patients. / O desempenho físico funcional reduzido antes da hospitalização prediz limitações de suporte de vida e mortalidade em pacientes não cirúrgicos de unidade de terapia intensiva.

OBJECTIVE: To assess whether scales of physical functional performance and the surprise question ("Would I be surprised if this patient died in 6 months?") predict life support limitations and mortality in critically ill nonsurgical patients. METHODS: We included 114 patients admitted from the Emergency Department to an intensive care unit in this prospective cohort. Physical functional performance was assessed by the Palliative Prognostic Score, Karnofsky Performance Status, and the Katz Activities of Daily Living scale. Two intensivists responded to the surprise question. RESULTS: The proposed physical functional performance scores were significantly lower in patients with life support limitations and those who died during the hospital stay. A negative response to the surprise question was more frequent in the same subset of patients. Adjusted univariable analysis showed an increased odds ratio for life support limitations and death regarding the activities of daily living scale (1.35 [1.01 - 1.78] and 1.34 [1.0 - 1.79], respectively) and a negative response for the surprise question (42.35 [11.62 - 154.43] and 47.79 [11.41 - 200.25], respectively); with a p < 0.05 for all results. CONCLUSION: All physical functional performance scales showed lower scores in nonsurvivors and patients with life support limitations. The activities of daily living score and the surprise question increased the odds of life support limitations and mortality in our cohort of nonsurgical intensive care unit patients admitted from the Emergency Department.

OBJETIVO: Avaliar se as escalas de desempenho físico funcional e a pergunta surpresa ("Eu ficaria surpreso se esse paciente morresse em 6 meses?") predizem limitações de suporte de vida e mortalidade em pacientes críticos não cirúrgicos. METÓDOS: Participaram desta coorte prospectiva 114 pacientes admitidos do serviço de emergência em uma unidade de terapia intensiva. O desempenho físico funcional foi avaliado pelo Palliative Prognostic Score, pela Escala de Desempenho de Karnofsky e pela escala de Atividades de Vida Diária de Katz. Dois intensivistas responderam à pergunta surpresa. RESULTADOS: Os escores de desempenho físico funcional propostos foram significativamente menores em pacientes com limitações de suporte de vida e naqueles que vieram a óbito durante a hospitalização. A resposta negativa à pergunta surpresa foi mais frequente no mesmo subgrupo de pacientes. A análise univariada ajustada mostrou aumento da razão de chances para limitações de suporte de vida e morte em relação à escala de Atividades de Vida Diária (1,35 [1,01 - 1,78] e 1,34 [1,0 - 1,79], respectivamente) e uma resposta negativa para a pergunta surpresa (42,35 [11,62 - 154,43] e 47,79 [11,41 - 200,25], respectivamente), com p < 0,05 para todos os resultados. CONCLUSÃO: Todas as escalas de desempenho físico funcional apresentaram escores mais baixos em não sobreviventes e em pacientes com limitações de suporte de vida. A redução da capacidade funcional prévia à internação e a resposta negativa à pergunta surpresa aumentaram as chances de limitações de suporte de vida e mortalidade em nossa coorte de pacientes não cirúrgicos da unidade de terapia intensiva com entrada no serviço de emergência.

O desempenho físico funcional reduzido antes da hospitalização prediz limitações de suporte de vida e mortalidade em pacientes não cirúrgicos de unidade de terapia intensiva / Reduced physical functional performance before hospitalization predicts life support limitations and mortality in nonsurgical intensive care unit patients

RESUMO Objetivo: Avaliar se as escalas de desempenho físico funcional e a pergunta surpresa ("Eu ficaria surpreso se esse paciente morresse em 6 meses?") predizem limitações de suporte de vida e mortalidade em pacientes críticos não cirúrgicos. Metódos: Participaram desta coorte prospectiva 114 pacientes admitidos do serviço de emergência em uma unidade de terapia intensiva. O desempenho físico funcional foi avaliado pelo Palliative Prognostic Score, pela Escala de Desempenho de Karnofsky e pela escala de Atividades de Vida Diária de Katz. Dois intensivistas responderam à pergunta surpresa. Resultados: Os escores de desempenho físico funcional propostos foram significativamente menores em pacientes com limitações de suporte de vida e naqueles que vieram a óbito durante a hospitalização. A resposta negativa à pergunta surpresa foi mais frequente no mesmo subgrupo de pacientes. A análise univariada ajustada mostrou aumento da razão de chances para limitações de suporte de vida e morte em relação à escala de Atividades de Vida Diária (1,35 [1,01 - 1,78] e 1,34 [1,0 - 1,79], respectivamente) e uma resposta negativa para a pergunta surpresa (42,35 [11,62 - 154,43] e 47,79 [11,41 - 200,25], respectivamente), com p < 0,05 para todos os resultados. Conclusão: Todas as escalas de desempenho físico funcional apresentaram escores mais baixos em não sobreviventes e em pacientes com limitações de suporte de vida. A redução da capacidade funcional prévia à internação e a resposta negativa à pergunta surpresa aumentaram as chances de limitações de suporte de vida e mortalidade em nossa coorte de pacientes não cirúrgicos da unidade de terapia intensiva com entrada no serviço de emergência.

ABSTRACT Objective: To assess whether scales of physical functional performance and the surprise question ("Would I be surprised if this patient died in 6 months?") predict life support limitations and mortality in critically ill nonsurgical patients. Methods: We included 114 patients admitted from the Emergency Department to an intensive care unit in this prospective cohort. Physical functional performance was assessed by the Palliative Prognostic Score, Karnofsky Performance Status, and the Katz Activities of Daily Living scale. Two intensivists responded to the surprise question. Results: The proposed physical functional performance scores were significantly lower in patients with life support limitations and those who died during the hospital stay. A negative response to the surprise question was more frequent in the same subset of patients. Adjusted univariable analysis showed an increased odds ratio for life support limitations and death regarding the activities of daily living scale (1.35 [1.01 - 1.78] and 1.34 [1.0 - 1.79], respectively) and a negative response for the surprise question (42.35 [11.62 - 154.43] and 47.79 [11.41 - 200.25], respectively); with a p < 0.05 for all results. Conclusion: All physical functional performance scales showed lower scores in nonsurvivors and patients with life support limitations. The activities of daily living score and the surprise question increased the odds of life support limitations and mortality in our cohort of nonsurgical intensive care unit patients admitted from the Emergency Department.

Near-fatal poisoning after ricin injection.

OBJECTIVE: To report a near-fatal poisoning after intentional injection of ricin from a castor bean (Ricinus communis) extract. CASE REPORT: A 21 year-old man self-injected ∼3 mL of a castor bean extract intramuscularly and subcutaneously in the left antecubital fossa. Upon admission to our ED (1 h post-exposure; day 1, D1) he was awake and alert, but complained of mild local pain and showed slight local edema and erythema. He evolved to refractory shock (∼24 h post-exposure) that required the administration of a large volume of fluids and high doses of norepinephrine and vasopressin, mainly from D2 to D4. During this period, he developed clinical and laboratory features compatible with systemic inflammatory response syndrome, multiple organ dysfunction, capillary leak syndrome, rhabdomyolysis, necrotizing fasciitis and possible compartment syndrome. The patient underwent forearm fasciotomy on D4 and there was progressive improvement of the hemodynamic status from D7 onwards. Wound management involved several debridements, broad-spectrum antibiotics and two skin grafts. Major laboratory findings within 12 days post-exposure revealed hypoalbuminemia, proteinuria, thrombocytopenia, leukocytosis and increases in cytokines (IL-6, IL-10 and TNF-α), troponin and creatine kinase. Ricin A-chain (ELISA) was detected in serum up to D3 (peak at 24 h post-exposure), with ∼79% being excreted in the urine within 64 h post-exposure. Ricinine was detected in serum and urine by LC-MS up to D5. A ricin A-chain concentration of 246 µg/mL was found in the seed extract, corresponding to the injection of ∼738 µg of ricin A-chain (∼10.5 µg/kg). The patient was discharged on D71, with limited range of motion and function of the left forearm and hand. CONCLUSION: Ricin injection resulted in a near-fatal poisoning that evolved with septic shock-like syndrome, multiple organ dysfunction and necrotizing fasciitis, all of which were successfully treated with supportive care.

Estudo genético-epidemiológico da hemoglobina S em uma população do Sudeste do Brasil / Genetic-epidemiological study of hemoglobin S in a population from Southeastern Brazil

A anemia falciforme, expressão clínica dos homozigotos do gene da hemoglobina S, é a doença hereditária mais freqüente no Brasil. Apesar disso, a metodologia genético-epidemiológica raramente é usada nos estudos brasileiros sobre essa alteração. No presente estudo foram analisados, por meio de um software específico, os dados de 817 heterozigotos do gene da HbS (513 homens e 304 mulheres), não consangüíneos, com idades entre 18 e 65 anos, detectados voluntariamente na cidade de Campinas, SP, Sudeste do Brasil. A constituição genômica caucasóide, negróide e indígena foi avaliada na amostra de portadores da hemoglobina S através do estudo das freqüências alélicas do sistema sangüíneo ABO e comparada com a observada na população geral da mesma cidade. A análise dos dados demonstrou que 52 por cento dos portadores da HbS tiveram sua ancestralidade africana evidenciada pelo seu fenótipo e que 36 por cento dos indivíduos eram procedentes do Nordeste do Brasil, sobretudo da Bahia (15 por cento). Essa imigração interna tende a diminuir a proporção do haplótipo Bantu da hemoglobina S (mais grave) na região de Campinas, aumentando a proporção do haplótipo Benin (mais benigno). A amostra possui um componente gênico negróide de 45 por cento, caucasóide de 41 por cento, e indígena de 14 por cento. Essa composição genômica é significativamente diferente da observada na população geral da mesma cidade, apresentando uma participação gênica maior de negróides e de indígenas (influência da imigração nordestina) e menor de caucasóides. A imigração nordestina e a miscigenação alteraram significativamente o perfil genético-epidemiológico dos portadores da hemoglobina S na região de Campinas, SP.

Sickle cell anemia, the clinical expression of individuals homozygous for the hemoglobin S gene, is the most frequent hereditary disease in Brazil. Nevertheless, a genetic-epidemiological approach is rarely used in Brazilian studies related to this alteration. In the present study, using a specific computer program, data from 817 (513 males and 304 females) non-consanguineous individuals heterozygous for the hemoglobin S gene were studied. The participants, with ages varying from 18 to 65 years old, live from the region of Campinas, Southeastern Brazil. The Caucasoid, Negroid and native Indian genomic backgrounds of this sample were evaluated by a study of allelic frequencies for the ABO blood group system and compared with those observed in the general population from the same city. Data analysis showed that: 52 percent of the hemoglobin S carriers had African ancestry as shown by their phenotypes and that 36 percent of the subjects came from North-eastern Brazil, most from the state of Bahia (15 percent). This internal migration tends to decrease the proportion of the hemoglobin S Bantu (wild) haplotype in the region of Campinas, by increasing the proportion of the Benin haplotype (milder). The frequencies of this sample were Negroes 45 percent, Caucasians 41 percent, and native Indians 14 percent. This genomic constitution is significantly different from that observed in the general population from the same city with greater frequencies of Negroes and native Indians and a lower frequency of Caucasians. Migration from the northeastern and miscegenation have significantly altered the genetic-epidemiological profile of hemoglobin S carriers in the region of Campinas.

A complexidade da mistura racial no Brasil: a hemoglobina S como marcador étnico nas suas populações / The complexity of racial admixture in Brazil: hemoglobin S as an ethnic marker in its population

Black people and mulattoes constitute circa 45% of the Brazilian population, and there exists quite a controversy concerning the correct use of the terms Negro, Negroid or Afro-descendant to name this ethnic category. Since the hemoglobin S gene comes predominantly from African descendants, the study of this genetic disorder contributes greatly to the discussion of such a polemic matter. Recently we studied a sample of 817 heterozygous non-consanguineous individuals for the hemoglobin S gene (513 males and 304 females), aged between 18 and 65 years, voluntarily detected in the population of Campinas, State of São Paulo, Brazil. An analysis of the subjects showed that only 53% of the individuals' African ancestry was revealed by his/her phenotype. The gene composition of the individuals in this sample estimated the Negroid gene stock contribution as 45%, the Caucasoid gene stock contribution as 41% and the remaining 14% due to Amerindian gene stock. These data demonstrate that the wide miscegenation that has occurred in Brazil, as well as many internal and external migration streams have dissociated the hemoglobin S from the color of the skin of its carriers. In face of the diversity of criteria used in ethnic classifications, we choose to adopt the term Negroid in our research, which has been well established in Population Genetics, and which is also based upon objective definition criteria.