Can we predict 1-year functional outcomes and mortality following hip fracture in middle-aged and geriatric patients at time of admission?

This study's purpose is to determine if patients treated for hip fracture at highest risk for poor functional outcomes, shorter time to death, and death within 1-year can be predicted at the time of admission. We hypothesized that the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool can be used to predict risk of these variables. Between February 2019-July 2020, 544 patients ≥ 55-years-old were treated for hip fracture [AO/OTA 31A/B, 32A/C]. Each patient's demographics, functional status, and injury details were used to calculate their respective risk (STTGMA) score at time of admission. Patients were divided into risk quartiles by STTGMA score. Patients were contacted by phone to complete EuroQol-5 Dimension (EQ5D-3L) questionnaires on functional status. Comparative analyses were conducted on outcomes and EQ5D-3L questionnaire results. 439 patients (80.7%) had at least 1-year follow-up. 82 patients (18.7%) died within 1-year after hospitalization. Mean STTGMA score was 1.67% ± 4.49%. The highest-risk cohort experienced a 42x (p < 0.01) and 2.5x (p = 0.01) increased rate of 1-year mortality compared to the minimal- and low-risk groups respectively. The highest-risk cohort had the shortest time to death (p = 0.015). The highest-risk cohort had the lowest EQ5D index (p < 0.01) and VAS scores (p < 0.01) along with the highest rate of 30 day readmission (p < 0.01) and the longest length of stay (p < 0.01). The STTGMA tool provides important prognostic information for middle-aged and geriatric hip fracture patients that can help modulate care levels. This information is useful when counseling patients, their families, and caregivers on expected outcomes.

Effects of dietary inclusion of 3 Nordic brown macroalgae on enteric methane emission and productivity of dairy cows.

Macroalgae are receiving increased attention as antimethanogenic feed additives for cattle, but most in vivo studies are limited to investigating effects of the red macroalgae Asparagopsis spp. Hence, this study aimed to investigate the CH4 mitigating potential of 3 brown macroalgae from the Northern Hemisphere when fed to dairy cows, and to study the effects on feed intake, milk production, feed digestibility, and animal health indicators. The experiment was conducted as a 4 × 4 Latin square design using 4 lactating rumen, duodenal, and ileal cannulated Danish Holstein dairy cows. The cows were fed a total mixed ration (TMR) without any macroalgae or the same TMR diluted with, on a dry matter basis, either 4% ensiled Saccharina latissima, 4% Ascophyllum nodosum (NOD), or 2% Sargassum muticum (MUT). Each period consisted of 14 d of adaptation, 3 d of digesta and blood sampling, and 4 d of gas exchange measurements using respiration chambers. Milk yield and dry matter intake (DMI) were recorded daily. Blood was sampled on d 13 and 16 and analyzed for health status indicators. None of the 3 species affected the CH4 emission. Moreover, milk yield and DMI were also unaffected. Total-tract digestibility of crude protein was significantly lower for NOD compared with other diets, and additionally, the NOD diet also tended to reduce total-tract digestibility of neutral detergent fiber compared with MUT. Blood biomarkers did not indicate negative effects of the dietary inclusion of macroalgae on cow health. In conclusion, none of the 3 brown macroalgae reduced CH4 emission and did not affect DMI and milk production of dairy cows, whereas negative effects on the digestibility of nutrients were observed when A. nodosum was added. None of the diets would be allowed to be fed in commercial dairy herds due to high contents of iodine, cadmium, and arsenic.

Recomendación Clínica: "Recomendaciones para el manejo de pacientes con COVID-19 con indicación terapéutica de ventilación mecánica que eventualmente son conectados a máquinas de anestesia" / Recommendations for patient management with COVID-19 with therapeutic indication mechanical ventilation that eventually are connected to anesthesia machines

La pandemia de COVID-19 producida por SARS-CoV-2 actualmente en curso anticipa una gran demanda por ventiladores mecánicos (VM), ya que un porcentaje relevante de los contagiados cae rápidamente en insuficiencia respiratoria y requiere de cuidados intensivos. Anticipándose a ese exceso de demanda y considerando que es muy probable que el número actual de ventiladores mecánicos en las unidades de cuidados intensivos (UCI) sean insuficientes, se ha solicitado a la SACH un informe técnico en relación al uso de las máquinas de anestesia como VM.

Evaluation of the Myo armband for the classification of hand motions.

Pattern recognition-based control systems have been widely investigated in prostheses and virtual reality environments to improve amputees' quality of life. Most of these systems use surface electromyography (EMG) to detect user movement intentions. The Myo armband (MYB) is a wireless wearable device, developed by Thalmic Labs, which enables EMG recordings with a limited bandwidth (<100Hz). The aim of this study was to compare MYB's narrow bandwidth with a conventional EMG acquisition system (CONV) that captures the full EMG spectrum to assess its suitability for pattern recognition control. A crossover study was carried out with eight able-bodied participants, performing nine hand gestures. Six features were extracted from the data and classified by Linear Discriminant Analysis (LDA). Results showed a mean classification error of 5.82 ± 3.63% for CONV and 9.86 ± 8.05% for MYB with no significantly difference (P = 0.056). This implies that MYB may be suitable for pattern recognition applications despite the limitation in the bandwidth.

Open lung approach ventilation abolishes the negative effects of respiratory rate in experimental lung injury.

BACKGROUND: We recently reported that a high respiratory rate was associated with less inflammation than a low respiratory rate, but caused more pulmonary edema in a model of ARDS when an ARDSNet ventilatory strategy was used. We hypothesized that an open lung approach (OLA) strategy would neutralize the independent effects of respiratory rate on lung inflammation and edema. This hypothesis was tested in an ARDS model using two clinically relevant respiratory rates during OLA strategy. METHODS: Twelve piglets were subjected to an experimental model of ARDS and randomized into two groups: LRR (20 breaths/min) and HRR (40 breaths/min). They were mechanically ventilated for 6 h according to an OLA strategy. We assessed respiratory mechanics, hemodynamics, and extravascular lung water (EVLW). At the end of the experiment, wet/dry ratio, regional histology, and cytokines were evaluated. RESULTS: After the ARDS model was established, Cdyn,rs decreased from 21 ± 3.3 to 9.0 ± 1.8 ml/cmH2 O (P < 0.0001). After the lung recruitment maneuver, Cdyn,rs increased to the pre-injury value. During OLA ventilation, no differences in respiratory mechanics, hemodynamics, or EVLW were observed between groups. Wet/dry ratio and histological scores were not different between groups. Cytokine quantification was similar and showed a homogeneous distribution throughout the lung in both groups. CONCLUSION: Contrary to previous findings with the ARDSNet strategy, respiratory rate did not influence lung inflammatory response or pulmonary edema during OLA ventilation in experimental ARDS. This indicates that changing the respiratory rate when OLA ventilation is used will not exacerbate lung injury.

High respiratory rate is associated with early reduction of lung edema clearance in an experimental model of ARDS.

BACKGROUND: The independent impact of respiratory rate on ventilator-induced lung injury has not been fully elucidated. The aim of this study was to investigate the effects of two clinically relevant respiratory rates on early ventilator-induced lung injury evolution and lung edema during the protective ARDSNet strategy. We hypothesized that the use of a higher respiratory rate during a protective ARDSNet ventilation strategy increases lung inflammation and, in addition, lung edema associated to strain-induced activation of transforming growth factor beta (TGF-ß) in the lung epithelium. METHODS: Twelve healthy piglets were submitted to a two-hit lung injury model and randomized into two groups: LRR (20 breaths/min) and HRR (40 breaths/min). They were mechanically ventilated during 6 h according to the ARDSNet strategy. We assessed respiratory mechanics, hemodynamics, and extravascular lung water (EVLW). At the end of the experiment, the lungs were excised and wet/dry ratio, TGF-ß pathway markers, regional histology, and cytokines were evaluated. RESULTS: No differences in oxygenation, PaCO2 levels, systemic and pulmonary arterial pressures were observed during the study. Respiratory system compliance and mean airway pressure were lower in LRR group. A decrease in EVLW over time occurred only in the LRR group (P < 0.05). Wet/dry ratio was higher in the HRR group (P < 0.05), as well as TGF-ß pathway activation. Histological findings suggestive of inflammation and inflammatory tissue cytokines were higher in LRR. CONCLUSION: HRR was associated with more pulmonary edema and higher activation of the TGF-ß pathway. In contrast with our hypothesis, HRR was associated with less lung inflammation.

High PEEP levels are associated with overdistension and tidal recruitment/derecruitment in ARDS patients.

BACKGROUND: Positive end-expiratory pressure (PEEP) improves gas exchange and respiratory mechanics, and it may decrease tissue injury and inflammation. The mechanisms of this protective effect are not fully elucidated. Our aim was to determine the intrinsic effects of moderate and higher levels of PEEP on tidal recruitment/derecruitment, hyperinflation, and lung mechanics, in patients with acute respiratory distress syndrome (ARDS). METHODS: Nine patients with ARDS of mainly pulmonary origin were ventilated sequential and randomly using two levels of PEEP: 9 and 15 cmH2 O, and studied with dynamic computed tomography at a fix transversal lung region. Tidal recruitment/derecruitment and hyperinflation were determined as non-aerated tissue and hyperinflated tissue variation between inspiration and expiration, expressed as percentage of total weight. We also assessed the maximal amount of non-aerated and hyperinflated tissue weight. RESULTS: PEEP 15 cmH2 O was associated with decrease in non-aerated tissue in all the patients (P < 0.01). However, PEEP 15 cmH2 O did not decrease tidal recruitment/derecruitment compared to PEEP 9 cmH2 O (P = 1). In addition, PEEP 15 cmH2 O markedly increased maximal hyperinflation (P < 0.01) and tidal hyperinflation (P < 0.05). Lung compliance decreased with PEEP 15 cmH2 O (P < 0.001). CONCLUSION: In this series of patients with ARDS of mainly pulmonary origin, application of high levels of PEEP did not decrease tidal recruitment/derecruitment, but instead consistently increased tidal and maximal hyperinflation.

Parkinson's disease: considerations for dental hygienists.

The prevalence of Parkinson's disease (PD) is expected to double over the next 20 years owing to the increase in life expectancy. This progressive disease has several implications relating to oral health, and many are manageable with proper awareness and knowledge about the disease. This article reviews the epidemiology, pathophysiology, and characteristics of PD, as well as the treatments and oral health considerations to enable dental hygienists to undertake an informed approach to patient management strategies and provide optimal care.

Tidal volume is a major determinant of cyclic recruitment-derecruitment in acute respiratory distress syndrome.

BACKGROUND: Overdistension and cyclic recruitment-derecruitment contribute to ventilator-induced lung injury. High tidal volumes are thought to increase mortality mainly by inducing overdistension. However, experimental evidence suggests that tidal volume (VT) may also influence cyclic recruitment-derecruitment. Our main goal was to determine whether high tidal volumes increase cyclic recruitment-derecruitment in acute respiratory distress syndrome (ARDS) patients, as measured by dynamic computed tomography (CT). METHODS: We studied 9 ARDS patients with diffuse attenuations on CT who underwent a protocol including 2 ventilatory modes: (a) VT 6 mL/kg, respiratory rate 30/min, PEEP 9 cmH2O, (b) VT 12 mL/kg, respiratory rate 15/min, PEEP 9 cmH2O. A dynamic computed tomography of 8 seconds on a fixed transverse region was performed during each ventilator mode. Cyclic recruitment-derecruitment was determined as non-aerated tissue variation between inspiration and expiration and was expressed as % of lung tissue weight. RESULTS: VT 12 mL/kg exhibited less non-aerated tissue at expiration compared to VT 6 ml/kg (40.15 [35.94-56.00] and 45.31 [37.95-59.32], respectively, P<0.05). However, VT 12 ml/kg increased cyclic recruitment-derecruitment compared to VT 6 mL/kg (7.32 [6.58-9.29] mL/kg vs. 4.51 [3.42-5.75] mL/kg, P<0.01). Tidal hyperinflation was also larger at VT 12 mL/kg (0.55 [0.27-2.24] vs. 0.24 [0.18-0.83], P<0.01). CONCLUSION: High tidal volume is a major determinant of cyclic recruitment-derecruitment in ARDS patients with diffuse attenuations.

Laparoscopic and robotic assisted adrenal surgery.

The aim of this paper is to review the current state of laparoscopic and robotic surgery in the mannagement of benign and malignant disease of the adrenal gland. Adrenal lesions can be adenomas, pheochromocytomas, myelolipomas, ganglioneuromas, adrenal cysts, hematomas, adrenal cortical carcinomas, metastases from other cancers, or other rare causes. Laparoscopic adrenalectomy (LA) has become the new standard of care for benign adrenal neoplasms and is being increasingly utilized for malignant disease. Robotic assistance offers unique advantages in visualizing and dissecting the adrenal gland, especially considering its challenging vasculature. Series of robotic adrenalectomy (RA) and LA show that techniques are both safe and effective compared to open. There is also growing evidence in using minimally invasive approaches in adrenal sparing-surgery. Success in these procedures depends on a firm understanding of adrenal anatomy and in careful patient selection. Both LA and RA are offer advantages to patients and are comparable in outcomes. RA offers the potential for increased visualization and faster learning curve which may allow for both faster, and more precise dissection, as well as increased utilization of minimally invasive techniques. While LA remains the standard of care, RA is an excellent option in high volume robotic centers from standpoints of outcomes, feasibility, and cost.

An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock.

BACKGROUND: Septic shock is highly lethal. We recently implemented an algorithm (advanced resuscitation algorithm for septic shock, ARAS 1) with a global survival of 67%, but with a very high mortality (72%) in severe cases [norepinephrine (NE) requirements >0.3 microg/kg/min for mean arterial pressure > or =70 mmHg]. As new therapies with different levels of evidence were proposed [steroids, drotrecogin alpha, high-volume hemofiltration (HVHF)], we incorporated them according to severity (NE requirements; algorithm ARAS-2), and constructed a multidisciplinary team to manage these patients from the emergency room (ER) to the ICU. The aim of this study was to compare the outcome of severe septic shock patients under both protocols. METHODS: Adult patients with severe septic shock were enrolled consecutively and managed prospectively with ARAS-1 (1999-2001), and ARAS-2 (2002-05). ARAS-2 incorporates HVHF for intractable shock. RESULTS: Thirty-three patients were managed with each protocol, without statistical differences in baseline demographics, APACHE II (22.2 vs 23.8), SOFA (11.4 vs 12.7) and NE peak levels (0.62 vs 0.8 microg/kg/min). The 28-day mortality and epinephrine use were higher with ARAS-1 (72.7% vs 48.5%; 87.9% vs 18.2 %); and low-dose steroids (35.9% vs 72.7%), drotrecogin (0 vs 15 %) and HVHF use (3.0% vs 39.4%) were higher for ARAS-2 (P<0.05 for all). CONCLUSION: Management of severe septic shock with a multidisciplinary team and an updated protocol (according to the best current evidence), with precise entry criteria for every intervention at different stages of severity, may improve survival in these patients. Multidisciplinary management, rationalization of the use of vasoactives and rescue therapy based on HVHF instead of epinephrine may have contributed to these RESULTS: Management of severe septic shock with these kinds of algorithms is feasible and should be encouraged.

Sepsis diagnosis and management: work in progress.

Severe sepsis is a common disease process in the critically ill and is associated with substantial morbidity and mortality. Continuing research has provided considerable insight into the pathophysiology of sepsis over recent years, enabling various aspects of the sepsis response to be targeted. Discoveries related to the link between coagulation and inflammation have been particularly exciting, leading to the development of recombinant activated protein C. This review will discuss current definitions of sepsis, describe new approaches to classification and diagnosis of patients with sepsis, present recommendations for management, and briefly highlight areas of ongoing and future research.

[Limitations of the technique to determine hydrogen peroxide levels in exhaled breath condensate from patients with adult respiratory distress syndrome]. / Limitaciones de la técnica de determinación de peróxido de hidrógeno en el condensado del aire espirado de pacientes con síndrome de distrés respiratorio del adulto.

OBJECTIVE: Exhaled breath condensate represents an alternative to bronchoalveolar lavage for the analysis of markers of inflammation and oxidative stress in patients with adult respiratory distress syndrome (ARDS). However, analysis of hydrogen peroxide (H2O2) yields variable results that do not correlate with severity of the clinical presentation. In an attempt to explain this variability, the aim of the present study was to assess the possible limitations of the most commonly used technique for analyzing H2O2 in breath condensate. PATIENTS AND METHODS: H2O2 levels were analyzed using the Gallati technique (linear range between 0.3 and 10 microM, r=0.99; P<.05) in serial samples of condensate taken from the expiratory tube of a mechanical ventilator in 6 patients with ARDS. RESULTS: The volume of condensate obtained correlated to minute ventilation (r=0.96; P<.05). In 11 out of 23 samples, a spectrophotometer reading was obtained at 450 nm despite the absence of the characteristic color of the reaction and in some of these samples a spontaneous reading was obtained that was indicative of contamination. The absorbance spectrum of these samples did not contain the characteristic peak for H2O2 at 450 nm and pretreatment of some samples with catalase did not affect the absorbance at 450 nm. CONCLUSIONS: The spectrophotometric method commonly used to measure H2O2 levels in breath condensate lacks specificity in ARDS due to the presence of variable levels of contaminants in the samples, which lead to false positives.

Atypical neuroleptic malignant syndrome caused by olanzapine.

OBJECTIVE: Neuroleptic malignant syndrome (NMS) is a rare syndrome with four main symptoms: rigidity, hyperthermia, altered mental status and autonomic instability. We report a patient with an atypical manifestation of NMS. METHOD: A single case was reported. RESULTS: A patient with pneumonia developed delirium and was treated with olanzapine and developed a NMS with fluctuating hyperthermia and autonomic instability during a month. Only slight rigidity was present. Creatine kinase was not elevated. The patient was severely agitated and manic. After discontinuation of olanzapine the patient showed no psychopathology or hyperthermia. CONCLUSION: NMS should be considered when patients treated with antipsychotics develop one or more symptoms of NMS.

[Preliminary experience with dexmedetomidine treatment of confusional state and hyperadrenergic states at an intensive care unit]. / Experiencia preliminar del tratamiento con dexmedetomidina del estado confusional e hiperadrenergia en la unidad de cuidados intensivos.

Delirium (confusion) is an acute, reversible and fluctuating compromise of awareness and cognitive function, a state that can increase morbidity and mortality. We describe four patients with delirium associated with agitation and hyperadrenergic states refractory to haloperidol but responsive to dexmedetomidine.

Influence of polymeric enteral nutrition supplemented with different doses of glutamine on gut permeability in critically ill patients.

OBJECTIVES: To evaluate the effect of glutamine-supplemented polymeric enteral formulas on the recovery of gut-permeability abnormalities in critically ill patients. METHODS: Twenty-three patients were randomized to receive a conventional casein-based enteral formula (ADN), ADN plus glutamine in a dose of 0.15 g x kg(-1) x d(-1) or ADN plus 0.30 g x kg(-1) x d(-1) of glutamine for 8 d. The lactulose mannitol permeability test (L/M) was performed at baseline and at the end of the study. Nineteen healthy volunteers served as controls for the L/M test. RESULTS: An increase in permeability compared with control subjects was observed in patients at baseline (mean +/- standard error of the mean; L/M ratio: 0.11 +/- 0.03 and 0.025 +/- 0.004, respectively; P < 0.02). The L/M ratio improved after the period of enteral nutrition as a whole (initial L/M: 0.11 +/- 0.03, final L/M: 0.061 +/- 0.01; P < 0.03), but no difference was found between groups. CONCLUSIONS: Even though polymeric enteral nutrition was associated with a significant improvement in the L/M ratio, glutamine supplementation did not show a specific influence in improving recovery of gut permeability in critically ill patients.

[Suprahepatic vein catheterization in 4 cases of severe septic shock]. / Cateterización venosa suprahepática en cuatro casos de shock séptico severo.

Splanchnic hypoperfusion, with pathogenic implications for multiple organ failure, can occur during septic shock. We report four patients with septic shock in whom regional hepatosplenic splanchnic perfusion was monitored through suprahepatic vein catheterization and gastric tonometry. Suprahepatic lactate and oxygen saturation showed splanchnic hypoperfusion in all patients. These parameters improved only in the patient that survived. Gastric tonometry was more inconsistent. We conclude that suprahepatic vein catheterization could have a role in the management of septic shock.