RESUMEN
BACKGROUND: Delirium is a common neurocognitive complication after cardiac surgery. The aim of this systematic review was to determine whether the administration of dexmedetomidine in the perioperative period decreases the incidence of postoperative delirium in adult patients undergoing cardiac surgery. METHODS: Central, CINAHL, Ovid Embase, Ovid Medline, and Web of Science databases were searched for RCTs of adult patients undergoing cardiac surgery where participants received i.v. dexmedetomidine or control in the perioperative period. The methods included systematic review, meta-analysis, and trial sequential analysis. The primary outcome was the incidence of postoperative delirium. Dichotomous outcomes were presented as risk ratio (RR) using the Mantel-Haenszel method, and continuous variables were presented as mean difference with the inverse variance method. RESULTS: Thirty trials, comprising 4090 patients, were included. With unselected inclusion of trials, dexmedetomidine vs control was associated with decreased incidence of postoperative delirium (12.4% vs 16.2%; RR=0.62; 95% confidence interval 0.44-0.86; P=0.005; I2=61%). If trials at high risk of bias were excluded, the incidence of postoperative delirium was not significantly different between groups (RR=0.71; 95% confidence interval 0.49-1.03; P=0.070; I2=58%). Postoperative delirium was not a reliably determined outcome across trials because of methodological and reporting limitations, including the heterogeneity of delirium diagnostic approach. Trial sequential analysis revealed that the optimal information size was not reached, and the Z-curve did not cross the trial sequential boundaries for benefit or futility. With respect to safety concerns, dexmedetomidine was not significantly associated with incident bradycardia or hypotension, or with the duration of mechanical ventilation. CONCLUSIONS: When trials at high risk of bias were excluded, the use of perioperative dexmedetomidine was not associated with decreased incidence of postoperative delirium. PROSPERO REGISTRATION NUMBER: CRD 42021252779.
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Procedimientos Quirúrgicos Cardíacos , Delirio , Dexmedetomidina , Adulto , Bradicardia/epidemiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Delirio/epidemiología , Delirio/prevención & control , Dexmedetomidina/uso terapéutico , Humanos , Incidencia , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & controlRESUMEN
BACKGROUND: Awake tracheal intubation is commonly performed with flexible bronchoscopes, but the emerging role of alternative airway devices, such as videolaryngoscopes, direct laryngoscopes, and optical stylets, has been recognised. METHODS: CENTRAL, CINAHL, EMBASE, MEDLINE, and Web of Science were searched for RCTs that compared flexible bronchoscopes, direct laryngoscopes, optical stylets and channelled or unchannelled videolaryngoscopes in adult patients having awake tracheal intubation were included. The co-primary outcomes were first-pass success rate and time to tracheal intubation. Continuous outcomes were extracted as mean and standard deviation, and dichotomous outcomes were converted to overall numbers of incidence. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. RESULTS: Twelve RCTs were included, none of which evaluated direct laryngoscopes. The first-pass success rate was not different between flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes, with the quality of evidence rated as moderate in view of imprecision. Optical stylets, followed by unchannelled videolaryngoscopes and then felxible bronchoscopes resulted in the shortest time to tracheal intubation, with the quality of evidence rated as high. No differences were shown between the airway devices with respect to the incidence of oesophageal intubation, change of airway technique, oxygen desaturation, airway bleeding, or the rate of hoarseness and sore throat. CONCLUSIONS: Flexible bronchoscopes, optical stylets, and channelled and unchannelled videolaryngoscopes were clinically comparable airway devices in the setting of awake trachela intubation and the time to tracheal intubation was shortest with optical stylets and longest with flexible bronchoscopes.
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Broncoscopía/instrumentación , Intubación Intratraqueal/instrumentación , Laringoscopía/instrumentación , Adulto , Broncoscopios , Diseño de Equipo , Humanos , Laringoscopios , Factores de Tiempo , Grabación en Video , VigiliaRESUMEN
In 2015, we founded Pedi Lyme Net, a pediatric Lyme disease research network comprising 8 emergency departments in the United States. Of 2,497 children evaluated at 1 of these sites for Lyme disease, 515 (20.6%) were infected. This network is a unique resource for evaluating new approaches for diagnosing Lyme disease in children.
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Borrelia burgdorferi , Ixodes , Enfermedad de Lyme , Animales , Bancos de Muestras Biológicas , Borrelia burgdorferi/genética , Niño , Humanos , Enfermedad de Lyme/diagnóstico , Enfermedad de Lyme/epidemiología , Estados Unidos/epidemiologíaRESUMEN
PURPOSE: Carbetocin has been shown to reduce the requirement for additional uterotonics in women exclusively undergoing elective Cesarean delivery (CD). The aim of this review was to determine whether this effect could also be demonstrated in the setting of non-elective CD. METHODS: Medline, Embase, CINAHL, Web of Science and Cochrane databases were searched for randomized-controlled trials (RCTs) in any language comparing carbetocin to oxytocin. Studies with data on women undergoing non-elective CD, where carbetocin was compared with oxytocin, were included. The primary outcome was the need for additional uterotonics. Secondary outcomes included incidence of blood transfusion, estimated blood loss (mL), incidence of postpartum hemorrhage (PPH; > 1000 mL) and mean hemoglobin drop (g·dL-1 RESULTS: Five RCTs were included, with a total of 1,214 patients. The need for additional uterotonics was reduced with carbetocin compared with oxytocin (odds ratio, 0.30; 95% CI, 0.11 to 0.86; I2, 90.60%). Trial sequential analysis (TSA) confirmed that the information size needed to show a significant reduction in the need for additional uterotonics had been exceeded. No significant differences were shown with respect to any of the secondary outcomes, but there was significant heterogeneity between the studies. CONCLUSIONS: Carbetocin reduces the need for additional uterotonics in non-elective CD compared with oxytocin. TSA confirmed that this analysis was appropriately powered to detect the pooled estimated effect. Further trials utilizing consistent core outcomes are needed to determine an effect on PPH. TRIAL REGISTRATION: PROSPERO CRD42019147256, registered 13 September 2019.
RéSUMé: OBJECTIF: Il a été démontré que la carbétocine réduisait les besoins en utérotoniques supplémentaires exclusivement chez les femmes subissant un accouchement par césarienne planifié. L'objectif de ce compte rendu était de déterminer si cela pouvait également être démontré dans le cas d'un accouchement par césarienne non planifié. MéTHODE: Les bases de données Medline, Embase, CINAHL, Web of Science et Cochrane ont été passées en revue pour en extraire les études randomisées contrôlées (ERC), toutes langues confondues, comparant la carbétocine à l'ocytocine. Les études comportant des données concernant des femmes subissant un accouchement par césarienne non planifié et comparant la carbétocine à l'ocytocine ont été incluses. Le critère d'évaluation principal était le besoin d'utérotoniques supplémentaires. Les critères secondaires comprenaient l'incidence de transfusion sanguine, la perte de sang estimée (mL), l'incidence d'hémorragie postpartum (HPP; > 1000 mL) et la baisse moyenne du taux d'hémoglobine (g·dL−1). RéSULTATS: Cinq ERC ont été retenues, incluant 1214 patientes au total. Les besoins en utérotoniques supplémentaires étaient plus faibles lors de l'utilisation de carbétocine par rapport à l'ocytocine (rapport de cotes, 0,30; IC 95 %, 0,11 à 0,86; I2, 90,60 %). L'analyse séquentielle des essais a confirmé que la taille des informations démontrant une réduction significative du besoin d'utérotoniques supplémentaires avait été dépassée. Aucune différence significative n'a été démontrée en ce qui touchait nos critères d'évaluation secondaires, mais l'hétérogénéité des études était considérable. CONCLUSION: La carbétocine réduit le besoin d'utérotoniques supplémentaires lors d'un accouchement par césarienne non planifié comparativement à l'ocytocine. L'analyse séquentielle des essais a confirmé que cette analyse disposait de suffisamment de puissance pour détecter l'effet estimé pondéré. Des études supplémentaires portant sur des critères constants sont nécessaires afin de déterminer un effet sur l'HPP. ENREGISTREMENT DE L'éTUDE: PROSPERO CRD42019147256, enregistrée le 13 septembre 2019.
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Oxitócicos , Hemorragia Posparto , Cesárea , Femenino , Humanos , Oxitocina/análogos & derivados , Hemorragia Posparto/epidemiología , Hemorragia Posparto/prevención & control , Embarazo , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
KEY MESSAGE: Key genes potentially involved in cacao disease resistance were identified by transcriptomic analysis of important cacao cultivars. Defense gene polymorphisms were identified which could contribute to pathogen recognition capacity. Cacao suffers significant annual losses to the water mold Phytophthora spp. (Oomycetes). In West Africa, P. megakarya poses a major threat to farmer livelihood and the stability of cocoa production. As part of a long-term goal to define key disease resistance genes in cacao, here we use a transcriptomic analysis of the disease-resistant cacao clone SCA6 and the susceptible clone NA32 to characterize basal differences in gene expression, early responses to infection, and polymorphisms in defense genes. Gene expression measurements by RNA-seq along a time course revealed the strongest transcriptomic response 24 h after inoculation in the resistant genotype. We observed strong regulation of several pathogenesis-related genes, pattern recognition receptors, and resistance genes, which could be critical for the ability of SCA6 to combat infection. These classes of genes also showed differences in basal expression between the two genotypes prior to infection, suggesting that prophylactic expression of defense-associated genes could contribute to SCA6's broad-spectrum disease resistance. Finally, we analyzed polymorphism in a set of defense-associated receptors, identifying coding variants between SCA6 and NA32 which could contribute to unique capacities for pathogen recognition. This work is an important step toward characterizing genetic differences underlying a successful defense response in cacao.
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Cacao/genética , Cacao/inmunología , Resistencia a la Enfermedad/genética , Resistencia a la Enfermedad/inmunología , Genotipo , Phytophthora/patogenicidad , Polimorfismo Genético , Perfilación de la Expresión Génica , Regulación de la Expresión Génica de las Plantas , Genes de Plantas/genética , Enfermedades de las Plantas/genética , Enfermedades de las Plantas/inmunología , Enfermedades de las Plantas/parasitología , Hojas de la Planta , ARN de Planta/aislamiento & purificación , TranscriptomaRESUMEN
Background: Integrase strand transfer inhibitors (INSTIs) are recommended by international guidelines as first-line therapy in antiretroviral-naive and -experienced HIV-1-infected patients. Objectives: This study aimed at evaluating the prevalence at failure of INSTI-resistant variants and the impact of baseline minority resistant variants (MiRVs) on the virological response to an INSTI-based regimen. Methods: Samples at failure of 134 patients failing a raltegravir-containing (n = 65), an elvitegravir-containing (n = 20) or a dolutegravir-containing (n = 49) regimen were sequenced by Sanger sequencing and ultra-deep sequencing (UDS). Baseline samples of patients with virological failure (VF) (n = 34) and of those with virological success (VS) (n = 31) under INSTI treatment were sequenced by UDS. Data were analysed using the SmartGene platform, and resistance was interpreted according to the ANRS algorithm version 27. Results: At failure, the prevalence of at least one INSTI-resistant variant was 39.6% by Sanger sequencing and 57.5% by UDS, changing the interpretation of resistance in 17/134 (13%) patients. Among 53 patients harbouring at least one resistance mutation detected by both techniques, the most dominant INSTI resistance mutations were N155H (45%), Q148H/K/R (23%), T97A (19%) and Y143C (11%). There was no difference in prevalence of baseline MiRVs between patients with VF and those with VS. MiRVs found at baseline in patients with VF were not detected at failure either in majority or minority mutations. Conclusions: UDS is more sensitive than Sanger sequencing at detecting INSTI MiRVs at treatment failure. The presence of MiRVs at failure could be important to the decision to switch to other INSTIs. However, there was no association between the presence of baseline MiRVs and the response to INSTI-based therapies in our study.
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Terapia Antirretroviral Altamente Activa/métodos , Farmacorresistencia Viral , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/virología , Inhibidores de Integrasa VIH/farmacología , Inhibidores de Integrasa VIH/uso terapéutico , VIH-1/efectos de los fármacos , Adulto , Femenino , Técnicas de Genotipaje , Infecciones por VIH/epidemiología , VIH-1/genética , VIH-1/aislamiento & purificación , Secuenciación de Nucleótidos de Alto Rendimiento , Humanos , Masculino , Persona de Mediana Edad , Paris/epidemiología , Prevalencia , Insuficiencia del TratamientoRESUMEN
OBJECTIVES: Transmitted drug resistance (TDR) can impair the response to first-line antiretroviral therapy. In treatment-naïve patients chronically infected with HIV type 1 (HIV-1), it was previously shown through Sanger sequencing that TDR was more common in men who have sex with men (MSM) than in other transmission risk groups. We aimed to compare two HIV-1 transmission groups in terms of the presence of TDR mutations. METHODS: We investigated, through Sanger sequencing and ultradeep sequencing (UDS), the presence of resistance mutations, both in majority (> 20%) and in minority (1-20%) proportions, in 70 treatment-naïve MSM and 70 treatment-naïve heterosexual patients who recently screened positive for HIV-1. RESULTS: The global prevalence of TDR was not significantly different between the two groups, either by Sanger or by UDS. Nevertheless, a higher frequency of nucleoside reverse transcriptase inhibitor TDR was observed among heterosexual patients (P = 0.04). There was also a trend for a higher frequency of TDR among MSM infected with HIV-1 subtype B compared with MSM infected with HIV-1 non-B subtypes (P = 0.06). CONCLUSIONS: Ultradeep sequencing UDS allowed sensitive monitoring of TDR, and highlighted some disparities between transmission groups.
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Farmacorresistencia Viral , Infecciones por VIH/virología , VIH-1/genética , Secuenciación de Nucleótidos de Alto Rendimiento/métodos , Análisis de Secuencia de ARN/métodos , Adulto , Fármacos Anti-VIH/farmacología , Femenino , VIH-1/clasificación , VIH-1/efectos de los fármacos , Heterosexualidad , Homosexualidad Masculina , Humanos , Masculino , Mutación , Inhibidores de la Transcriptasa Inversa/farmacologíaRESUMEN
BACKGROUND: The use of phenylephrine as the first-line agent for prevention and treatment of maternal hypotension during cesarean delivery (CD) may reduce cardiac output, posing a theoretical risk to mother and fetus. Norepinephrine has been suggested as a potential alternative, because its ß-adrenergic effects might result in greater heart rate and cardiac output than phenylephrine. The use of norepinephrine to prevent and treat hypotension during CD is new, and its use as a bolus has not been fully determined in this context. The purpose of this study was to determine the effective norepinephrine dose, when given as intermittent intravenous (IV) boluses, to prevent postspinal hypotension in 90% of women undergoing elective CD (ED90). METHODS: This was a prospective, double-blind sequential allocation dose-finding study, using the biased coin up-and-down design. Forty-term pregnant women undergoing elective CD under spinal anesthesia received a set intermittent norepinephrine bolus of either 3, 4, 5, 6, 7, or 8 µg every time their systolic blood pressure (SBP) fell to below 100% of baseline. The primary outcome was the success of the norepinephrine regimen to maintain SBP at or above 80% of baseline, from induction of spinal anesthesia to delivery of the fetus. Secondary outcomes included nausea, vomiting, hypertension (SBP > 120% of baseline), bradycardia (<50 bpm), upper sensory level of anesthesia to ice cold and umbilical artery and vein blood gases. The ED90 and 95% confidence intervals (CIs) were estimated using both truncated Dixon and Mood and isotonic regression methods. RESULTS: The estimated ED90 of norepinephrine was 5.49 µg (95% CI, 5.15-5.83) using the truncated Dixon and Mood method and 5.80 µg (95% CI, 5.01-6.59) using the isotonic regression method. CONCLUSIONS: The use of intermittent IV norepinephrine boluses to prevent spinal-induced hypotension in elective CD seems feasible and was not observed to be associated with adverse outcomes. Practically, we suggest an ED90 dose of 6 µg. Further work is warranted to elucidate the comparative effects of intermittent IV bolus doses of phenylephrine and norepinephrine, in terms of efficacy and safety.
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Anestesia Raquidea/efectos adversos , Cesárea/efectos adversos , Hipotensión/prevención & control , Norepinefrina/administración & dosificación , Administración Intravenosa , Adulto , Anestesia Obstétrica/efectos adversos , Presión Sanguínea/efectos de los fármacos , Gasto Cardíaco/efectos de los fármacos , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Esquema de Medicación , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Humanos , Hipotensión/inducido químicamente , Fenilefrina/administración & dosificación , Embarazo , Resultado del Embarazo , Estudios Prospectivos , Receptores Adrenérgicos beta/metabolismo , Sístole/efectos de los fármacos , Vasoconstrictores/administración & dosificaciónRESUMEN
PURPOSE: There is growing evidence to suggest a deficiency in anesthesiologists' diagnosis of airway pathology and subsequent airway management planning, and conventional instruments have not shown increases in safety. Virtual endoscopy (VE) is a tool that can detail intraluminal anatomical "fly-through" information in a format visually similar to the flexible endoscopic views familiar to anesthesiologists. We aimed to determine the effect of VE on diagnostic accuracy and airway management strategies when compared with conventional tools. METHODS: Clinical scenarios, along with computerized tomography (CT) imaging, were presented to 20 anesthesiologists, and structured questions were asked regarding diagnosis of airway pathology and airway management strategy. Virtual endoscopy videos were then provided and the questions were repeated. Following the CT and VE presentations, the anesthesiologists' responses involving diagnostic accuracy and airway management strategy were compared between the CT and VE techniques. Answers relating to the utility of VE were also sought. RESULTS: Diagnostic accuracy was 54.1% with CT alone and increased to 67.7% when VE was added (P = 0.007). In 48% of cases, the addition of VE to clinical history and CT led to changes in airway management strategy (P < 0.001), and 90.6% of these changes were deemed more cautious (P < 0.001). CONCLUSION: Virtual endoscopy improves the accuracy in diagnosis of airway pathology when compared with CT alone. Furthermore, it leads to more conservative and potentially safer airway management strategies in patients with head and neck pathology.
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Manejo de la Vía Aérea/métodos , Endoscopía/métodos , Cabeza/diagnóstico por imagen , Cuello/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Estudios de Cohortes , Humanos , Interpretación de Imagen Asistida por Computador/métodos , Estudios Prospectivos , Reproducibilidad de los Resultados , Interfaz Usuario-ComputadorRESUMEN
PURPOSE: The purpose of this study was to determine the contractile patterns induced by oxytocin in myometrium exposed to magnesium sulfate (MgSO4). We hypothesized that MgSO4 pretreatment would reduce oxytocin-induced myometrial contractions in both oxytocin-naïve and oxytocin-desensitized myometrium. METHODS: In this prospective in vitro study, myometrial samples were obtained from 26 women undergoing elective Cesarean deliveries. Samples were divided into six groups. Four groups were apportioned to no pretreatment (control group), oxytocin 10-5 M pretreatment (desensitization group), MgSO4 3.5 mM pretreatment, and MgSO4 3.5 mM + oxytocin 10-5M pretreatment. This was followed by dose-response testing to oxytocin 10-10 to 10-5M in all four groups. Two additional groups included MgSO4 3.5 mM pretreatment and MgSO4 3.5 mM + oxytocin 10-5 M pretreatment, followed by dose-response testing to oxytocin along with MgSO4 3.5 mM. The outcomes were motility index (MI), as defined by the amplitude (g) × frequency of myometrial contractions (c) over ten minutes, and area under the curve (AUC). RESULTS: In oxytocin-naïve myometrium, the mean (standard error [SE]) MI was not affected by MgSO4 pretreatment [3.31 (0.20) âgâ c/10 min] as compared with control (P = 0.88), even when MgSO4 was continued during dose-response testing [2.50 (0.19) âgâ c/10 min; P = 0.41]. In the oxytocin-desensitized model, mean (SE) MI was not affected by MgSO4 pretreatment [2.60 (0.21) âgâ c/10 min; P = 0.68], but when MgSO4 was continued during the dose-response period, the MI was significantly reduced compared with control [1.89 (0.13) âgâ c/10 min; P < 0.001]. The results for AUC were similar to MI, except for a significant reduction in oxytocin-naïve myometrium when MgSO4 was continued during dose-response testing (P = 0.02). CONCLUSION: Magnesium sulfate pretreatment does not impair oxytocin-induced myometrial contractility in oxytocin-naïve or desensitized myometrium unless it is continued during oxytocin dose-response testing. These results suggest that its tocolytic effect is likely dependent on an extracellular mechanism. The study was registered with ClinicalTrials.gov, number NCT02647268.
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Sulfato de Magnesio/farmacología , Oxitócicos/farmacología , Oxitocina/farmacología , Contracción Uterina/efectos de los fármacos , Adulto , Cesárea , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Humanos , Técnicas In Vitro , Sulfato de Magnesio/administración & dosificación , Miometrio/efectos de los fármacos , Miometrio/metabolismo , Oxitócicos/administración & dosificación , Oxitocina/administración & dosificación , Embarazo , Estudios Prospectivos , Factores de Tiempo , Tocolíticos/administración & dosificación , Tocolíticos/farmacologíaRESUMEN
Hepatitis B (HBV) virus infection is characterized by the overproduction of subviral particles (SVP) over infectious Dane particles (VP). Precise regulation of the ratio between these forms is unknown, but its fluctuation may have a clinical impact. An enrichment method was applied to assess the SVP/VP ratio in chronically infected patients (CHB) and to compare the sensitivity of HBs antigen (HBsAg) and DNA detection methods. Plasmas from 9 genotype A-D CHB patients were fractionated on Nycodenz(®) gradients, and both HBV DNA and HBsAg were quantified in each collected fraction using standardized techniques expressed in IU/mL. Infection of primary human hepatocytes (PHHs) was performed with crude or fractionated plasma. Independently of the genotype, all plasmas showed a similar rate-zonal separation profile characterized by a bottom DNA-enriched peak surmounted by HBsAg-enriched fractions. Inoculation of PHH with plasma-derived VP-enriched fractions led to long-lasting production of virus in cell supernatants with a SVP/VP ratio similar to that observed in patient plasmas. In the VP fraction, one IU of HBsAg corresponded to approximately 5 million IU of HBV DNA. Rate-zonal gradient separation directly applied on patient plasma allows a better insight into the distribution of VP in HBeAg-positive CHB carriers. This study highlights the sensitivity difference of the techniques classically used to monitor HBV infection and indicates that VP-associated HBsAg contributes modestly to the overall amount of total circulating HBsAg in CHB. Such a fractionation approach should help to understand the fine regulation of HBsAg production over replication at different stages of CHB.
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ADN Viral/sangre , Antígenos de Superficie de la Hepatitis B/sangre , Virus de la Hepatitis B/aislamiento & purificación , Hepatitis B Crónica/diagnóstico , Hepatitis B Crónica/virología , Adulto , Células Cultivadas , Pruebas Diagnósticas de Rutina/métodos , Hepatocitos/virología , Humanos , Sensibilidad y EspecificidadAsunto(s)
Anestesia Raquidea , Norepinefrina , Cesárea , Femenino , Humanos , Hipotensión , EmbarazoRESUMEN
BACKGROUND: Cesarean section is associated with moderate to severe pain and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly employed. The optimal NSAID, however, has not been elucidated. In this network meta-analysis and systematic review, we compared the influence of control and individual NSAIDs on the indices of analgesia, side effects, and quality of recovery. METHODS: CDSR, CINAHL, CRCT, Embase, LILACS, PubMed, and Web of Science were searched for randomized controlled trials comparing a specific NSAID to either control or another NSAID in elective or emergency cesarean section under general or neuraxial anesthesia. Network plots and league tables were constructed, and the quality of evidence was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis. RESULTS: We included 47 trials. Cumulative intravenous morphine equivalent consumption at 24 h, the primary outcome, was examined in 1,228 patients and 18 trials, and control was found to be inferior to diclofenac, indomethacin, ketorolac, and tenoxicam (very low quality evidence owing to serious limitations, imprecision, and publication bias). Indomethacin was superior to celecoxib for pain score at rest at 8-12 h and celecoxib + parecoxib, diclofenac, and ketorolac for pain score on movement at 48 h. In regard to the need for and time to rescue analgesia COX-2 inhibitors such as celecoxib were inferior to other NSAIDs. CONCLUSIONS: Our review suggests the presence of minimal differences among the NSAIDs studied. Nonselective NSAIDs may be more effective than selective NSAIDs, and some NSAIDs such as indomethacin might be preferable to other NSAIDs.
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Diclofenaco , Ketorolaco , Humanos , Embarazo , Femenino , Diclofenaco/uso terapéutico , Ketorolaco/uso terapéutico , Celecoxib/uso terapéutico , Cesárea/efectos adversos , Metaanálisis en Red , Antiinflamatorios no Esteroideos/efectos adversos , Indometacina/uso terapéutico , Dolor/tratamiento farmacológicoRESUMEN
OBJECTIVES: Amino acid insertions in the protease gene have been reported rarely, and mainly in patients receiving protease inhibitors (PIs). The aim of the study was to assess the long-term viro-immunological follow-up of HIV-infected patients harbouring virus with protease insertions. METHODS: Cases of virus exhibiting protease insertions were identified in routine resistance genotyping tests. Therapeutic, immunological and virological data were retrospectively collected. RESULTS: Eleven patients harbouring virus with a protease gene insertion were detected (prevalence 0.24%), including three PI-naïve patients. The insertions were mainly located between codons 33 and 39 and associated with surrounding mutations (M36I/L and R41K). The three PI-naïve patients were infected with an HIV-1 non-B subtype. Follow-up of these PI-naïve patients showed that the insert-containing virus persisted for several years, was archived in HIV DNA, and displayed a reduced viral replicative capacity with no impact on resistance level. Of the eight PI-experienced patients, 63% were infected with HIV-1 subtype B; one had been antiretroviral-free for 5 years and seven were heavily PI-experienced (median duration of follow-up 24 months; range 10-62 months). The protease insertion was selected under lopinavir in four patients and under darunavir in one, in the context of major PI-resistance mutations, and following long-term exposure to PIs. The insert-containing virus persisted for a median of 32 months (range 12-62 months) and displayed no specific impact on phenotypic resistance level or viral replicative capacity. CONCLUSION: Our data, obtained during long-term follow-up, show that insertions in the protease gene do not seem to have an impact on resistance level. This finding supports the recommendation of PI-based regimens, although further work is required to confirm it.
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Infecciones por VIH/tratamiento farmacológico , Inhibidores de la Proteasa del VIH/uso terapéutico , VIH-1/genética , Mutagénesis Insercional/genética , Péptido Hidrolasas/genética , Codón , Resistencia a Medicamentos/genética , Genes Virales , Genotipo , Infecciones por VIH/genética , Humanos , FenotipoRESUMEN
GOAL OF THE STUDY: A detection and quantification method specific of genotype G hepatitis B virus (G-HBV) was developed and used to study the epidemiology and evolution of G-HBV co-infection during antiviral therapy. PATIENTS AND METHODS: A multiplex real time PCR was developed and validated on A-HBV and G-HBV plasmid mixes. G-HBV infection was sought for on chronic hepatitis B carriers followed in our institution. RESULTS: Two primers, flanking the specific G-HBV 36 nucleotide insertion and two probes, including one specific for the insertion, were validated for a multiplex real time PCR. This new tool was well correlated to commercially available quantification systems within a 2 to 7 log(10) IU/mL range. On A- and G-HBV clonal mixes, G-HBV was quantified with a precision between 5 to 10%. On HBV-HIV infected patients, a 25% G-HBV prevalence was found, while it was below 1% in HBV mono-infected patients. Longitudinal G-HBV quantifications on five treated patients indicate that G-HBV is not selected by antiviral treatment. CONCLUSION: A specific method for G-HBV quantification within multi-genotype mixes was set up. The important G-HBV prevalence in HIV patients was unexpected. Our data are not in favour of an intrinsic resistance of G-HBV to current antivirals.
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Sistemas de Computación , Virus de la Hepatitis B/genética , Hepatitis B/virología , Reacción en Cadena de la Polimerasa/métodos , Antivirales/uso terapéutico , Secuencia de Bases , Comorbilidad , Secuencia Conservada , ADN Viral/genética , Farmacorresistencia Viral , Estudios de Seguimiento , Genotipo , Infecciones por VIH/epidemiología , Hepatitis B/tratamiento farmacológico , Hepatitis B/epidemiología , Virus de la Hepatitis B/efectos de los fármacos , Virus de la Hepatitis B/aislamiento & purificación , Humanos , Datos de Secuencia Molecular , Mutagénesis Insercional , Sondas de Oligonucleótidos , Prevalencia , Juego de Reactivos para Diagnóstico , Alineación de Secuencia , Homología de Secuencia de Ácido Nucleico , Carga ViralRESUMEN
STUDY OBJECTIVE: Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery. DESIGN: Systematic review and network meta-analysis. SETTING: Operating room, postoperative recovery room and ward. PATIENTS: Patients scheduled for breast surgery under general anesthesia. INTERVENTIONS: Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced. MEASUREMENTS: Co-primary outcomes were the pain at rest at 0-2 h and 8-12 h. Secondary outcomes were those related to analgesia, side effects and functional status. MAIN RESULTS: In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0-2 and 8-12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8-12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques. CONCLUSIONS: In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.
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Anestesia de Conducción , Neoplasias de la Mama , Bloqueo Nervioso , Anestesia de Conducción/efectos adversos , Femenino , Humanos , Bloqueo Nervioso/efectos adversos , Metaanálisis en Red , Dolor Postoperatorio/epidemiología , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & controlRESUMEN
Dioscorea alata (L.), also referred to as water, winged, or greater yam, is one of the most economically important staple food crops in tropical and subtropical areas. In Côte d'Ivoire, it represents, along with other yam species, the largest food crop and significantly contributes to food security. However, studies focusing on better understanding the structure and extent of genetic diversity among D. alata accessions, using molecular and phenotypic traits, are limited. This study was, therefore, conducted to assess the pattern of genetic variability in a set of 188 D. alata accessions from the National Agronomic Research Centre (CNRA) genebank using 11,722 SNP markers (generated by the Diversity Arrays Technology) and nine agronomic traits. Phylogenetic analyses using hierarchical clustering, admixture, kinship, and Discriminant analysis of principal component (DAPC) all assigned the accessions into four main clusters. Genetic diversity assessment using molecular-based SNP markers showed a high proportion of polymorphic SNPs (87.81%). The analysis of molecular variance (AMOVA) showed low molecular variability within genetic groups. In addition, the agronomic traits evaluated for two years in field conditions showed a high heritability and high variability among D. alata accessions. This study provides insights into the genetic diversity among accessions in the CNRA genebank and opens an avenue for sustainable resource management and the identification of promising parental clones for water yam breeding programs in Côte d'Ivoire.
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Block rooms allow parallel processing of surgical patients with the purported benefits of improving resource utilization and patient outcomes. There is disparity in the literature supporting these suppositions. We aimed to synthesize the evidence base for parallel processing by conducting a systematic review and meta-analysis. A systematic search was undertaken of Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Health Service (NHS) National Institute for Health Research Centre for Reviews and Dissemination database, and Google Scholar for terms relating to regional anesthesia and block rooms. The primary outcome was anesthesia-controlled time (ACT; time from entry of the patient into the operating room (OR) until the start of surgical prep plus surgical closure to exit of patient from the OR). Secondary outcomes of interest included other resource-utilization parameters such as turnover time (TOT; time between the exit of one patient from the OR and the entry of another), time spent in the postanesthesia care unit (PACU), OR throughput, and clinical outcomes such as pain scores, nausea and vomiting, and patient satisfaction. Fifteen studies were included involving 8888 patients, of which 3364 received care using a parallel processing model. Parallel processing reduced ACT by a mean difference (95% CI) of 10.4 min (16.3 to 4.5; p<0.0001), TOT by 16.1 min (27.4 to 4.8; p<0.0001) and PACU stay by 26.6 min (47.1 to 6.1; p=0.01) when compared with serial processing. Moreover, parallel processing increased daily OR throughout by 1.7 cases per day (p<0.0001). Clinical outcomes all favored parallel processing models. All studies showed moderate-to-critical levels of bias. Parallel processing in regional anesthesia appears to reduce the ACT, TOT, PACU time and improved OR throughput when compared with serial processing. PROSPERO CRD42018085184.
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Anestesia de Conducción , Medicina Estatal , Anestesia de Conducción/efectos adversos , Humanos , Quirófanos , Satisfacción del PacienteRESUMEN
Severe upper airway obstruction is commonly managed with surgical tracheostomy under local anesthesia. We present a 49-year-old woman with postradiotherapy laryngeal fixation and transglottic stenosis for dilation of a pharyngeal stricture who refused elective tracheostomy. A 2-stage technique was used, which involved an awake fiberoptic intubation, followed by the transtracheal insertion of a Cricath needle and ventilation using an ejector-based Ventrain device. We discuss management aspects of this clinical scenario and the principles by which the Ventrain works.
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INTRODUCTION: Team-based training and simulation can improve patient safety, by improving communication, decision making, and performance of team members. Currently, there is no general consensus on whether or not a specific assessment tool is better adapted to evaluate teamwork in obstetric emergencies. The purpose of this qualitative systematic review was to find the tools available to assess team effectiveness in obstetric emergencies. METHODS: We searched Embase, Medline, PubMed, Web of Science, PsycINFO, CINAHL, and Google Scholar for prospective studies that evaluated nontechnical skills in multidisciplinary teams involving obstetric emergencies. The search included studies from 1944 until January 11, 2016. Data on reliability and validity measures were collected and used for interpretation. A descriptive analysis was performed on the data. RESULTS: Thirteen studies were included in the final qualitative synthesis. All the studies assessed teams in the context of obstetric simulation scenarios, but only six included anesthetists in the simulations. One study evaluated their teamwork tool using just validity measures, five using just reliability measures, and one used both. The most reliable tools identified were the Clinical Teamwork Scale, the Global Assessment of Obstetric Team Performance, and the Global Rating Scale of performance. However, they were still lacking in terms of quality and validity. CONCLUSIONS: More work needs to be conducted to establish the validity of teamwork tools for nontechnical skills, and the development of an ideal tool is warranted. Further studies are required to assess how outcomes, such as performance and patient safety, are influenced when using these tools.