Exploring the Association of Metabolic Syndrome with In-Hospital Survival of Older Patients Hospitalized with COVID-19: Beyond Chronological Age.

BACKGROUND: Despite the variability and complexity of geriatric conditions, few COVID-19 reports of clinical characteristic prognostication provide data specific to oldest-old adults (over age 85), and instead generally report broadly as 65 and older. OBJECTIVE: To examine metabolic syndrome criteria in adults across 25 hospitals with variation in chronological age. DESIGN AND PARTICIPANTS: This cohort study examined 39,564 hospitalizations of patients aged 18 or older with COVID-19 who received inpatient care between March 13, 2020, and February 28, 2022. EXPOSURE: ICU admission and/or in-hospital mortality. MAIN MEASURES: Metabolic syndrome criteria and patient demographics were examined as risk factors. The main outcomes were admission to ICU and hospital mortality. KEY RESULTS: Oldest old patients (≥ 85 years) hospitalized with COVID-19 accounted for 7.0% (2758/39,564) of all adult hospitalizations. They had shorter ICU length of stay, similar overall hospitalization duration, and higher rates of discharge destinations providing healthcare services (i.e., home health, skilled nursing facility) compared to independent care. Chronic conditions varied by age group, with lower proportions of diabetes and uncontrolled diabetes in the oldest-old cohort compared with young-old (65-74 years) and middle-old (75-84 years) groups. Evaluations of the effect of metabolic syndrome and patient demographics (i.e., age, sex, race) on ICU admission demonstrate minimal change in the magnitude of effect for metabolic syndrome on ICU admission across the different models. CONCLUSIONS: Metabolic syndrome measures are important individual predictors of COVID-19 outcomes. Building on prior examinations that metabolic syndrome is associated with death and ARDS across all ages, this analysis supports that metabolic syndrome criteria may be more relevant than chronological age as risk factors for poor outcomes attributed to COVID-19.

Seguridad alimentaria y nutricional de niños menores de 5 años: de la dimensión alimentaria a la nutricional / Food and Nutrition Security of Children under 5 Years: From Food to Nutritional Dimension / Segurança alimentar e nutricional de crianças menores de 5 anos: da dimensão alimentar à nutricional

Objetivo: analizar la asociación de características biológicas y sociales con la seguridad alimentaria y nutricional (san) de niños menores de 5 años con base en indicadores de percepción del hambre y antro-pométricos.Materiales y métodos: estudio transversal realizado en municipios brasileños que fueron priorizados para el desarrollo de acciones de prevención de la obesidad infantil en 2017/2018. La san se midió usando la Escala Brasileña de Inseguridad Alimentaria y se utilizaron los índices antropométricos Talla/Edad (T/E), Peso/Edad (P/E) y Peso/Talla (P/T). Las asociaciones se testaron por regresión de Poisson con varianza robusta.Resultados: de los 868 niños, el 24.3 % vivía en familias con inseguridad alimenta-ria y nutricional moderada-severa (ianm-s), el 7.0 % tenía T/E baja; el 7.8 % P/E alto, y el 14.4 %, P/T alto. Si bien la ianm-s se asoció con una amplia gama de factores negativos del contexto social, las prevalencias de las desviaciones antropométricas fueron mayores en menores de 2 años y cuando las madres tenían el mismo diagnóstico nutricional que el niño.Conclusión: a pesar de las prevalencias expresivas de ianm-sy desviaciones antropométricas, la ianm-s fue más pronunciada, especialmente en contextos sociales des-favorables. La san mostró un comportamiento diferente en sus dimensiones alimentaria y nutricional, tanto en términos de frecuencia como de determinación

Objective: To analyze the association between biological and social characteristics with the food and nutritional security (fns) of children aged <5 years based on hunger perception and anthropometric indicators. Materials and methods: This cross-sectional study was performed at Brazilian municipali-ties that have been prioritized for the development of actions aimed at preventing childhood obesity in 2017­2018. The fns aspect was analyzed with reference to the Brazilian Food Insecurity Scale and the anthropometric indices Height/Age (H/A), Weight/Age (P/A), and Weight/Height (P/H) were used. The associations were tested by the Poisson Regression with robust variance. Results: Of the 868 children, 24.3 % lived in families with moderate­severe food and nutritional insecurity, 7.0 % had low H/A, 7.8 % had high P/A, and 14.4% had high P/E. The moderate­severe food and nutritional insecurity was associ-ated with a wide range of negative factors in the social context, but the prevalence of anthropometric deviations was higher in children <2 years and when their mothers had the same nutritional diagno-sis. Conclusion: Despite the expressive prevalence of moderate­severe food and nutritional insecurity and anthropometric deviations, the former was more pronounced, especially under unfavorable social contexts. san displayed different behaviors in its food and nutritional dimensions, both in the terms of frequency and determination.

Objetivo: analisar a associação de características biológicas e sociais com a Segurança Alimentar e Nutricional (san) de crianças menores de 5 anos com base em indicadores de percepção da fome e antropométricos. Materiais e métodos: estudo transversal realizado em municípios brasileiros que foram priorizados para o desenvolvimento de ações de prevenção da obesidade infantil em 2017/2018. A san foi medida usando a Escala Brasileira de Insegurança Alimentar e utilizaram-se os índices antropométricos Estatura/Idade (E/I), Peso/Idade (P/I) e Peso/Estatura (P/E). As associações se testaram por Regressão de Poisson com variância robusta. Resultados: das 868 crianças, 24.3 % residiam em famílias com Insegurança Alimentar e Nutricional Moderada-Grave (ianm-g), 7.0 % tinham E/I baixa, 7.8 % P/I elevado e 14.4 % P/E elevado. Enquanto a ianm-gassociou-se a uma ampla gama de fatores negativos do contexto social, as prevalências dos desvios antropo-métricos foram maiores em menores de 2 anos e quando as mães tiveram o mesmo diagnóstico nutricional que a criança. Conclusão: apesar das prevalências expressivas de ianm-g e de desvios antropométricos, a ianm-gfoi mais acentuada, sobretudo em contextos sociais desfavoráveis. A san manifestou comportamento dife-rente nas suas dimensões alimentar e nutricional, tanto em termos de frequência quanto de determinação.

La cosmovisión indígena en políticas públicas medioambientales para reducir la contaminación durante la pandemia del coronavirus / coronavirusIndigenous Worldview in Environmental Public Policies to Reduce Pollution during the Coronavirus Pandemic / A cosmovisão indígena nas políticas públicas ambientais de redução da poluição durante a pandemia do coronavírus

Introducción: consecuencia de la pandemia a causa del coronavirus (SARS-CoV-2), desde el 2020 ha aumen-tado la generación de los residuos con riesgo biológico o infeccioso, usados en los protocolos de biosegu-ridad por parte de la ciudadanía en general y el talento humano en salud. Ello generó un alto riesgo para salud y un aumento en el índice de contaminación ambiental y degradación de los recursos naturales, que hasta el momento ha superado las expectativas para su mitigación. Desarrollo: para contrarrestar el impacto del aumento en el índice de contaminación ambiental, se reflexiona sobre la necesidad de buscar acciones medioambientales para mitigar el daño y ampliar el concepto sobre el medio ambiente y la importancia de la interacción y codependencia del ser humano con la naturaleza. Se plantea la idea de retomar elementos conceptuales del conocimiento de las culturas indígenas sobre la visión holística del ambiente, partiendo de una cosmovisión indígena del buen vivir, donde el ambiente y el ser humano se encuentran en constante equilibrio y armonía. Conclusión: se pretende encontrar, desde la cosmovisión indígena, posibles abordajes conceptuales que mitiguen el impacto de la contaminación ambiental a causa del coronavirus, así como la formulación de acciones estratégicas para la adecuada gestión de estos residuos

Introduction: Since 2020, due to the the Coronavirus (SARS-CoV-2) pandemic, there has been an increase in generation of waste with biological or infectious risk used in biosafety protocols by the community and human resources in health, which, in turn, generates a high rate of pollution and environmental degradation of natural resources that has so far exceeded expectations for mitigation.Development: To reduce the impact of this problematic situation, a reflection was made to strengthen the current public policies and implement environmental actions that seek to mitigate the damage, but, above all, to change the concept of the environment and increase awareness about the importance of interac-tion and codependency of human beings with nature. The idea of retaking conceptual elements of the knowledge of indigenous cultures regarding the holistic vision of the environment is proposed, starting from a Quechua worldview of good living, where the environment and the human being are in constant balance and harmony. Conclusions:This study is intended to determine, from the indigenous worldview, the possible conceptual approaches that mitigate the environmental impact, as well as to formulate strategic actions for the adequate management of the resultant waste.

Introdução: como consequência da pandemia causada pelo Coronavírus (SARS-CoV-2), desde 2020 houve um aumento na geração de resíduos com risco biológico ou infeccioso utilizados em protocolos de bios-segurança pelo público em geral e talentos humanos em saúde; o que gerou um alto risco à saúde e um aumento no índice de contaminação ambiental e degradação dos recursos naturais que até agora tem superado as expectativas para sua mitigação. Desenvolvimento: para neutralizar o impacto do aumento do índice de contaminação ambiental, é feita uma reflexão sobre a necessidade de buscar ações ambien-tais para mitigar os danos, e ampliar o conceito de meio ambiente e a importância da interação e code-pendência do ser humano com a natureza. Propõe-se a ideia de retomar elementos conceituais do conhe-cimento das culturas indígenas sobre a visão holística do meio ambiente, partindo de uma cosmovisão indígena do bem viver, onde o meio ambiente e o ser humano estão em constante equilíbrio e harmonia. Conclusão: pretende-se encontrar a partir da visão de mundo indígena, possíveis abordagens conceituais que mitiguem o impacto da contaminação ambiental devido ao coronavírus, bem como a formulação de ações estratégicas para o gerenciamento adequado desses resíduos

Co-design of a Community-based Rehabilitation Program to Decrease Musculoskeletal Disabilities in a Mayan-Yucateco Municipality.

BACKGROUND: Chronic musculoskeletal (MSK) diseases are an important cause of disability in the Mayan community of Chankom in Yucatán, Mexico. OBJECTIVE: To understand a community-based participatory research (CBPR) strategy implemented in Chankom to design a community-based rehabilitation (CBR) program for people living with MSK diseases. METHODS: Qualitative descriptive thematic analysis from an ethnographic work conducted in Chankom, during the implementation of a CBPR strategy from 2014 to 2017. RESULTS: Four main themes describe the main processes that formed our CBPR strategy: 1) forming and maintaining an alliance between academic and community members, 2) prioritizing community needs, 3) integrating local and global knowledge and 4) shared-decision-making. This CBPR strategy allowed the design of a CBR program formed by six main interventions: 1) health services coordination, 2) personal support, 3) community venous blood sampling services, 4) community specialized services, 5) health promotion, and 6) health transportation services. CONCLUSIONS: Co-designing a CBR program for people living with chronic MSK diseases in Chankom was possible through an extensive community engagement work structured around four main processes, including the essential principles of CBPR. The designed CBR program includes culturally sensitive interventions aimed at improving the quality, availability, accessibility, and acceptability of health care services. Moreover, the program mainly addressed the "health" component of the World Health Organization-CBR matrix, suggesting a need for a new CBPR cycle after it is implemented and evaluated in the future.

[Comparison of different tools for the evaluation of malnutrition and sarcopenia in patients with liver cirrhosis]. / Comparación de distintas herramientas para la evaluación de la malnutrición y la sarcopenia en pacientes con cirrosis hepática.

Introduction: Introduction: malnutrition and sarcopenia are frequent in the population with liver cirrhosis and have a negative impact on the performance status and life expectancy of these patients. There are multiple assessment tools for malnutrition and sarcopenia in cirrhosis. Objective: to assess malnutrition and sarcopenia in liver cirrhosis and to compare the accuracy of diagnostic tools in this population. Method: a cross-sectional analytical study was conducted with convenience sampling by using continuous inclusion of patients with liver cirrhosis in a tertiary care center during December 2018 to May 2019. The nutritional assessment was carried out with arm anthropometry, body mass index (BMI), and the algorithm of the Royal Free Hospital Subjective Global Assessment (RFH-SGA). For the evaluation of sarcopenia, the hand grip strength test with a hand dynamometer was applied. The results were reported in measures of central tendency expressed in frequency and percentage. Results: a total of 103 patients were included with a predominance of the male gender (79.6 %) and a mean age of 51 years (± 10). The etiology of liver cirrhosis corresponded more frequently to alcohol consumption (68 %) and most of the patients were Child-Pugh C (57.3 %) with a mean MELD of 21.9 (± 8.9). A mean BMI with dry weight of 25.2 kg/m2 was reported, and with respect to the WHO classification by BMI, 7.8 % were underweight and 59.2 % were malnourished by RFH-SGA. Sarcopenia was present in 88.3 % using the hand grip strength test, for which a mean of 18.99 kg was found. A Kendall's Tau-b rank correlation coefficient was performed between BMI and RFH-SGA, which showed no statistically significant association, as well as between mean arm muscle circumference percentiles and hand grip strength. Conclusions: global assessment in liver cirrhosis should include screening for malnutrition and sarcopenia, for which validated, accessible and safe application tools should be used, such as anthropometric assessment, RFH-SGA, and hand grip strength.

Introducción: Introducción: la malnutrición y la sarcopenia son frecuentes en la población con cirrosis hepática y generan un impacto negativo en el estado funcional y la esperanza de vida de estos pacientes. Existen múltiples herramientas para la valoración de la malnutrición y la sarcopenia en los pacientes con cirrosis hepática. Objetivo: valorar la malnutrición y la sarcopenia en la cirrosis hepática y comparar distintas herramientas diagnósticas aplicables en esta población. Método: se realizó un estudio analítico de corte transversal con muestreo a conveniencia mediante inclusión continua de pacientes con cirrosis hepática en un hospital de tercer nivel durante diciembre de 2018 a mayo de 2019. Se realizó la valoración nutricional con la antropometría del brazo, el índice de masa corporal (IMC) y el algoritmo del Royal Free Hospital Subjetive Global Assessment (RFH-SGA). Para la valoración de la sarcopenia se aplicó la fuerza de agarre de la mano con un dinamómetro. Los resultados se reportaron en medidas de tendencia central expresadas en frecuencia y porcentaje. Resultados: se incluyeron un total de 103 pacientes, predominando el género masculino (79,6 %), con una edad media de 51 años. La etiología más frecuente de la cirrosis hepática fue el consumo de alcohol (68 %), predominando la clase Child-Pugh C (57,3 %) con una media de MELD de 21,9 (± 8,9). Se reportó una media de IMC con peso seco de 25,2 kg/m2 y, respecto a la clasificación de la OMS, un 7,8 % se encontraban en bajo peso y un 59,2 % en malnutrición según la RFH-SGA. Un 88,3 % presentó sarcopenia al utilizar la fuerza de agarre de la mano, cuyo valor medio fue de 18,99 kg. Se realizó una correlación con Tau b de Kendall entre IMC y RFH-SGA sin evidenciarse ninguna asociación significativa, al igual que entre los percentiles de la circunferencia muscular media de brazo (MAMC) y la fuerza de agarre de la mano. Conclusiones: la valoración integral de la cirrosis hepática debe incluir el escrutinio de la malnutrición y la sarcopenia, existiendo herramientas de fácil acceso y aplicación segura validadas en esta población, como la valoración antropométrica, el RFH-SGA y la fuerza de agarre de la mano.

Daily Oxygenation Support for Patients Hospitalized With SARS-CoV-2 in an Integrated Health System.

BACKGROUND: Many COVID-19 studies are constructed to report hospitalization outcomes, with few large multi-center population-based reports on the time course of intra-hospitalization characteristics, including daily oxygenation support requirements. Comprehensive epidemiologic profiles of oxygenation methods used by day and by week during hospitalization across all severities are important to illustrate the clinical and economic burden of COVID-19 hospitalizations. METHODS: This was a retrospective, multi-center observational cohort study of 15,361 consecutive hospitalizations of patients with COVID-19 at 25 adult acute care hospitals in Texas participating in the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study COVID-19 registry. RESULTS: At initial hospitalization, the majority required nasal cannula (44.0%), with an increasing proportion of invasive mechanical ventilation in the first week and particularly the weeks to follow. After 4 weeks of acute illness, 69.9% of adults hospitalized with COVID-19 required intermediate (eg, high-flow nasal cannula, noninvasive ventilation) or advanced respiratory support (ie, invasive mechanical ventilation), with similar proportions that extended to hospitalizations that lasted ≥ 6 weeks. CONCLUSIONS: Data representation of intra-hospital processes of care drawn from hospitals with varied size, teaching and trauma designations is important to presenting a balanced perspective of care delivery mechanisms employed, such as daily oxygen method utilization.

Position statement on the use of albumin in liver cirrhosis.

Cirrhosis is characterised by a prolonged asymptomatic period in which the inflammation persists, increasing as the disease progresses. Characteristic of this is the increase in pro-inflammatory cytokines and pro-oxidant molecules which are determining factors in the development of multiple organ dysfunction. In the early development of cirrhosis, splanchnic arterial vasodilation, activation of vasoconstrictor systems (renin-angiotensin-aldosterone) and the sympathetic nervous system (noradrenaline) bring about bacterial translocation and systemic dissemination via portal circulation of bacterial products, and molecular patterns associated with damage, which exacerbate the systemic inflammation present in the patient with cirrhosis. Albumin is a molecule that undergoes structural and functional changes as liver damage progresses, affecting its antioxidant, immunomodulatory, oncotic and endothelial stabilising properties. Our knowledge of the properties of albumin reveals a molecule with multiple treatment options in patients with cirrhosis, from the compensated then decompensated phases to multiple organ dysfunction. Its recognised uses in spontaneous bacterial peritonitis, post-paracentesis circulatory dysfunction, acute kidney injury and hepatorenal syndrome are fully validated, and a treatment option has opened up in decompensated cirrhosis and in acute-on-chronic liver disease.

Pesticides in water and sediments of Chacahua-Pastoria Lagoon System, Oaxaca, Mexico.

This is the first report about the presence of pesticide residues in water and sediments from Chacahua-Pastoria Lagoon System in the Oaxaca Coast, Mexico. Organochlorine and organophosphate pesticides were analyzed in water and sediment samples collected during rainy and dry seasons in 2018. The pesticides extraction was carried out by 525.2 EPA and QuEChERS methods for water and sediments samples, respectively. The quantification was done by gas chromatography coupled to electron microcapture (µECD) and flame photometric (FPD) detectors. Univariate and multivariate analysis were carried out to evaluate the distribution patterns, comparing between lagoons, seasons and matrices. The spatial distribution of malathion and organochlorines in water showed the highest values near to adjacent land with some patterns differences. DDT was the most frequent in water and sediments samples, showed the highest concentrations in the Pastoria Lagoon. These results indicate the need to establish a permanent monitoring programs to implement mitigation measures.

Evolution of practice patterns in the management of acute respiratory distress syndrome: A secondary analysis of two successive randomized controlled trials.

PURPOSE: We sought to examine changes in acute respiratory distress syndrome (ARDS) management over a 12-year period of two successive randomized trials. METHODS: Analyses included baseline data, from eligible patients, prior to influence of trial protocols, and daily study data, from randomized patients, of variables not determined by trial protocols. Mixed linear regressions examined changes in practice year-on-year. RESULTS: A total of 2376 patients met the inclusion criteria. Over the 12-year period, baseline tidal volume index decreased (9.0 to 7.0 ml/kg, p < 0.001), plateau pressures decreased (30.8 to 29.0 cmH2O, p < 0.05), and baseline positive end-expiratory pressures increased (10.8 to 13.2 cmH2O, p < 0.001). Volume-controlled ventilation declined from 29.4 to 14.0% (p < 0.01). Use of corticosteroids increased (baseline: 7.7 to 30.3%; on study: 32.6 to 61.2%; both p < 0.001), as did neuromuscular blockade (baseline: 12.3 to 24.5%; on study: 55.5 to 70.0%; both p < 0.01). Inhaled nitric oxide use increased (24.9 to 65.8%, p < 0.05). We observed no significant change in prone positioning (16.2 to 18.9%, p = 0.70). CONCLUSIONS: Clear trends were apparent in tidal volume, airway pressures, ventilator modes, adjuncts and rescue therapies. With the exception of prone positioning, and outside the context of rescue therapy, these trends appear consistent with the evolving literature on ARDS management.

Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS): Study protocol for peer mentor training.

AIMS: The primary aim of the Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS) peer mentor training trial is to determine the feasibility for peer mentor training to connect new ICU survivors with survivors who have made successful recoveries. Secondary aims are to also examine peer mentor eligibility, recruitment and retention rates and assess changes in participant knowledge of Post Intensive Care Syndrome (PICS), reported symptoms and health-related quality of life. DESIGN: Prospective clinical feasibility trial. METHODS: This study received funding from the National Institutes of Health funded P30 Center for Excellence (2014-2020). Up to 20 adult patients who have had an ICU stay of 3 days or longer more than 3 months ago will be enrolled into the study. Participants will undergo a 6-week peer mentor training program to learn how to promote healthy self-management behaviours, social connections, and well-being using motivational interviewing (MI). Participants will complete surveys about their recovery at 3 points during the study: prior to training, 6 weeks post-training and 3 months post-training. Survey questions will be used to assess trends in participant social isolation, depression, functional status, and self-management behaviours. DISCUSSION: Enrollment closes by December 2020. As a feasibility trial, power sufficient for hypothesis testing will not be available. However, study operations and intervention fidelity contribute to future research knowledge and participant characteristics and longitudinal outcomes will yield data on intervention feasibility. This study is the first use of embedding peer-led motivational interviewing training into a peer support intervention for ICU survivors. IMPACT: Current self-management interventions are limited for ICU survivors and do not sufficiently address barriers to promoting self-management behaviours or improving their health status, well-being and cost of health. This study will provide data to develop and implement interventions for the self-management of PICS-related symptoms and sequelae.

Relación entre el tiempo de circulación extracorpórea y el pinzamiento aórtico con diferentes variables de evolución postquirúrgicas / Relationship between cardiopulmonary bypass time and aortic cross clamping time with different variables of post-surgical evolution

Resumen Justificación: La mayor cantidad de cirugías cardiacas realizadas a nivel mundial se efectúa con circulación extracorpórea y pinzamiento de la aorta, lo que conlleva una serie de alteraciones fisiopatológicas que deben ser reconocidas por el personal de salud que participa en la atención de estos pacientes. Objetivo: Describir el perfil y los factores de riesgo presentes en los pacientes sometidos a cirugía cardiaca con circulación extracorpórea, y analizar la existencia de una potencial relación entre el tiempo de circulación extracorpórea y el pinzamiento aórtico, con la aplicación de desfibrilaciones tras al pinzado de la aorta, la necesidad de soporte cardiovascular farmacológico, el comportamiento del nivel de lactato plasmático y la mortalidad. Métodos: Se desarrolló un estudio observacional y descriptivo con una muestra de 104 pacientes electivos, sometidos a intervención quirúrgica y circulación extracorpórea, en el Hospital México, desde octubre de 2016 a noviembre de 2017. Se caracterizó la población en estudio, se analizaron los factores de riesgo incluido el EuroSCORE I y II, el tiempo de circulación extracorpórea, el tiempo de pinzamiento aórtico, las desfibrilaciones posteriores al pinzamiento aórtico, e lactato inmediatamente postcirculación extracorpórea, y a las 2, 6, 24 h postquirúrgicas, el uso de soporte cardiovascular farmacológico en infusión continua posterior a la circulación extracorpórea y mortalidad a los 30 días. Resultados: La edad media fue 56,4 años, predominó el sexo masculino (69 %) y la hipertensión arterial fue el factor de riesgo más frecuente (76,07 %). Se registró un tiempo de pinzado aórtico menor a 100 min en 61 pacientes (58,65 %) y superior a ese tiempo en 43 pacientes (41,35 %). El EuroSCORE I promedio fue del 4,21 % (DE: 4,80), mientras que el EuroSCORE II fue del 2,37 % (DE: 2,41). El tiempo promedio de circulación extracorpórea fue de 129 minutos (DE: 36,88) y el de pinzado aórtico, de 94 minutos (DE:32,04). Hubo un pico de lactato a las 6 horas postquirúrgicas (5,13 mmol/L, DE:2,89); un 8,65 % de los pacientes fueron desfibrilados después del retiro de la pinza en la aorta; se utilizó soporte cardiovascular en el 16,35 % y la mortalidad quirúrgica fue del 1,92 %. Conclusiones: En el estudio, el tiempo de circulación extracorpórea y el pinzado aórtico junto con el uso de inotrópicos, vasoconstrictores, hiperlactatemia y mortalidad quirúrgica, no alcanzó una relación significativa.

Abstract Justification: Currently, the largest number of cardiac surgeries performed worldwide are performed with cardiopulmonary bypass and aortic cross clamp, which leads to a series of pathophysiological alterations that are important for health personnel involved in the care of these patients. Objective: To describe the profile and risk factors present in patients undergoing cardiac surgery with cardiopulmonary bypass and the existence of a potential relationship between the cardiopulmonary bypass time and aortic cross clamping time, with the use of post clamp defibrillations, pharmacological cardiovascular support, plasma lactate behavior and mortality. Methods: An observational and descriptive study was carried out with a sample of 104 elective patients, undergoing surgical intervention and cardiopulmonary bypass at Hospital México, from October 2016 to November 2017. The study population was characterized, risk factors were analyzed including EuroSCORE I and II, CPB time, aortic cross clamping time, post-aortic clamping defibrillation, lactate immediately after extracorporeal circulation and at 2, 6, 24 hours postoperatively, use of pharmacological cardiovascular support in continuous infusion after extracorporeal circulation and mortality at 30 days. Results: The mean age was 56.4 years, the male sex predominated (69%) and arterial hypertension was the most frequent risk factor (76.07%). Aortic cross clamp time of less than 100 min was recorded in 61 patients (58.65%) and greater than that time in 43 patients (41.35%). The average EuroSCORE I was 4.21% (SD: 4.80), while the EuroSCORE II was 2.37% (SD: 2.41). The average cardiopulmonary bypass time was 129 minutes (SD: 36.88) and aortic cross clamp time was 94 minutes (SD: 32.04). There was a lactate peak at 6 postoperative hours (5.13 mmol/L, SD: 2.89); 8.65% of patients were defibrillated after removal the clamp in the aorta; pharmacological cardiovascular support was used in 16.35% and surgical mortality was 1.92%. Conclusions: In this study, cardiopulmonary bypass time and aortic cross clamp time together with the use of inotropics, vasoconstrictors, hyperlactatemia and surgical mortality did not reach a significant relationship.

Reinterpreting the role of primary and secondary airports in low-cost carrier expansion in Europe.

This paper discusses the long-term effects of low-cost carrier (LCC) presence at European airports and identifies the airports that have benefited the most from LCC consolidation since 2001. The research uses 'LCC Market Share', in terms of seats, to measure the relative importance of LCCs within each airport; and introduces 'EU LCA Rank' as a normalised metric of the capacity share of every airport in the European low-cost segment. It evaluates the trends between 2001 and 2019 in all airports in Europe using OAG supply information (seats by carrier). Results show two different phases of LCC rise in Europe, 2001 to 2008 and 2009 to 2019, marked by the effects of the financial crisis of the Great Recession. The analysis highlights the role that LCCs have played in boosting the growth of both primary and secondary airports. Indeed, despite the fact that LCCs have put many smaller airports on the European map, during the second phase of the period of analysis growth has been more significant for major airports and for a few airports that were keen to support the earliest development of LCCs. In that sense, this paper contributes to a better understanding of the historical and contemporary dynamics in European LCCs choice of airports and, in particular, the long-term effects that this disruptive business model have had for airports. This is increasingly important in the context of a potential recovery path from the effects of the response to the Covid-19 pandemic. This paper also attempts to settle academic discussions that attach LCC development to secondary/regional airports disregarding the wide range of strategies used by airlines and airports.

Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project.

IMPORTANCE: There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. OBJECTIVE: To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. PROCESS: Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. EVIDENCE SYNTHESIS: Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. RECOMMENDATIONS: Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. CONCLUSIONS AND RELEVANCE: This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

Reestructuración del abordaje de la patología estructural cardiaca en tiempos de pandemia por COVID-19 / Restructuring of the approach to structural pathology Cardiac in times of pandemic by COVID-19

Resumen La red sanitaria en el entorno de la pandemia por COVID-19 ha sufrido un gran impacto. La reorganización de la misma ha sido fundamental para poder atender la emergencia sanitaria, y en algunos países, ha sido incluso de forma abrupta. La atención oportuna de las enfermedades cardiovasculares continúa siendo una prioridad por la elevada mortalidad que ella implica especialmente en estadios muy avanzados de la enfermedad, y la modificación en la atención médica en el contexto actual no puede afectar la asistencia de patologías cardíacas. Los programas de cardiología estructural y cirugía cardíaca en nuestro país se han consolidado y crecido en los últimos años, ofreciendo múltiples procedimientos percutáneos o mínimamente invasivos para cardiopatías de alta morbimortalidad. La continuación de los mismos, a pesar de las dificultades por la pandemia, es necesaria en ciertos casos. Este documento reúne las principales recomendaciones basados en textos internacionales al respecto, para mantener el cuidado cardiovascular en Costa Rica pese al COVID-19 en el ámbito de la cardiopatía estructural.

Abstract The health system in the context of the COVID-19 pandemic has suffered a great impact. Thus, organization has been essential in maintaining the ability to respond to the health emergency, and in some countries, it has even been abrupt. The treatment of cardiovascular diseases continues to be a priority, and the modification of medical care in the current context cannot affect the timely procedures of cardiac pathologies. The structural cardiology and cardiac surgery programs in our country have been consolidated and grown in recent years, offering multiple percutaneous or minimally invasive procedures for heart disease with high morbidity and mortality. Their continuation, despite the difficulties caused by the outbreak, is necessary in certain cases. This document brings together the main recommendations based on international guidelines and experts opinions in this regard, to maintain cardiovascular care in Costa Rica despite COVID-19.

Body Mass Index and Mortality in Subjects With ARDS: Post-hoc Analysis of the OSCILLATE Trial.

BACKGROUND: Studies on the association of obesity with mortality in subjects with ARDS have yielded inconsistent results. METHODS: In a sub-analysis of the Oscillation for ARDS Treated Early (OSCILLATE) randomized controlled trial, 451 subjects were divided into 5 strata based on their body mass index (BMI) using the World Health Organization definitions: underweight < 18.5 kg/m2; normal weight 18.5-24.99 kg/m2; overweight 25-29.99 kg/m2; obese 30-39.99 kg/m2; severely obese > 40 kg/m2. The primary outcome was all-cause hospital mortality across BMI strata for all subjects and for the 2 study arms (high-frequency oscillatory ventilation [HFOV] vs conventional ventilation) separately using multivariable logistic regression adjusting for potential confounding variables. RESULTS: Hospital mortality was not different across the BMI strata for all subjects (P = .86), for the HFOV arm (P = .94) or for the conventional ventilation arm (P = .59). After risk adjustment, BMI was not associated with increased risk for hospital mortality (odds ratio 1.01, 95% CI 0.97-1.04, P = .67), whereas HFOV was independently associated with increased mortality (odds ratio 1.74, 95% CI 1.11-2.72, P = .02) with no effect modification by BMI strata (for this interaction, P = .56). Although there was no difference in the use of rescue therapies or in the number of days on sedation or analgesia, higher daily doses of fentanyl and midazolam were administered as BMI increased. CONCLUSION: There was no difference in adjusted hospital mortality across BMI strata in subjects with moderate to severe ARDS. Processes of care were not different across BMI strata except for higher daily doses of fentanyl as BMI increased. (ClinicalTrials.gov registration NCT0150640).

Can proactive rapid response team rounding improve surveillance and reduce unplanned escalations in care? A controlled before and after study.

BACKGROUND: Unplanned escalations manifest as a breakdown of hospital care attributable to clinician error through missed or delayed identification of physiological instability, ineffective treatment, or iatrogenic harm. OBJECTIVES: To examine the impact of an Early Warning Score-based proactive rapid response team model on the frequency of unplanned intra-hospital escalations in care compared with a rapid response team model based on staff nurse identification of vital sign derangements. DESIGN: Pre- and post Early Warning Score-guided proactive rapid response team model intervention. SETTING: 237-bed community hospital in the southeastern United States. PARTICIPANTS: All hospitalized adults (n = 12,148) during a pre- and post-intervention period. METHODS: Logistic regressions used to examine the relationship between unplanned ICU transfers and rapid response team models (rapid response team vs. Early Warning Score-guided proactive rapid response team). RESULTS: Unplanned ICU transfers were 1.4 times more likely to occur during the rapid response team baseline period (OR = 1.392, 95% CI [1.017-1.905]) compared with the Early Warning Score-guided proactive rapid response team intervention period. CONCLUSIONS: This study reports a difference in the frequency of unplanned escalations using different rapid response models, with fewer unplanned ICU transfers occurring during the use of Early Warning Score-guided proactive rapid response team model while accounting for differences in admission volumes, age, gender and comorbidities. Implementation of this model has implications for patient outcomes, hospital operations and costs.