Pharmacy stewardship to reduce recurrent hypoglycemia.

BACKGROUND: Inpatient hypoglycemia is associated with increased morbidity and mortality. After a hypoglycemic event, the likelihood of additional episodes increases. The Joint Commission recommends evaluating all episodes of hypoglycemia for root-cause analysis. Studies have shown that pharmacists' involvement with glycemic control protocols can prevent hypoglycemia. OBJECTIVES: This study aimed to assess whether the implementation of pharmacists' real-time assessment of hypoglycemic events using an electronic alert messaging system contributes to the reduction of the number of recurrent hypoglycemia during hospitalization. PRACTICE DESCRIPTION: A community hospital that provides a wide range of health care services. The pharmacy department provides fully decentralized clinical services and team-based specialist services. PRACTICE INNOVATION: The pharmacist-led hypoglycemia stewardship initiative included a comprehensive review of hypoglycemic alerts received via an automated message. The alerts generated in the electronic health record (EHR) every time a patient's blood glucose resulted in less than 70 mg/dL if there was a documented administration of a hypoglycemic agent 48 hours before the hypoglycemia event. Once the alert was received by the pharmacists via an EHR in-basket, a real-time review was conducted to identify the potential causes of the event and opportunities for therapy modification. EVALUATION METHODS: A single-center retrospective observational study including a pre- and post-implementation phase from January 1 to June 3, 2020, and January 1 to June 30, 2021, respectively. Continuous data were analyzed using paired and equal variance t test. Noncontinuous data were analyzed using Fisher exact and chi-square test. Descriptive statistics were used to describe distribution and frequency of data. RESULTS: There was a 5.1% absolute reduction in recurrent hypoglycemic events (P < 0.001) and a 0.6% reduction of severe hypoglycemic days (P = 0.269) in the postimplementation group. The average time to pharmacist intervention was 4 (± 3.5) hours with a 92% acceptance rate. CONCLUSION: This study demonstrated the utility of pharmacist-led hypoglycemia reviews in the reduction of recurrent hypoglycemic events in the inpatient setting.

Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors.

OBJECTIVES: The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP). PRACTICE DESCRIPTION: This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods. RESULTS: The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11). CONCLUSION: Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

Reprint of Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors.

OBJECTIVES: The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP). PRACTICE DESCRIPTION: This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods. RESULTS: The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11). CONCLUSION: Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

Cost-Consequence Analysis of Single-Dose Dalbavancin Versus Standard of Care for the Treatment of Acute Bacterial Skin and Skin Structure Infections in a Multisite Healthcare System.

BACKGROUND: Acute bacterial skin and skin structure infections (ABSSSIs) are common infectious diseases that cause a significant economic burden on the healthcare system. This study aimed to compare the cost-effectiveness of dalbavancin vs standard of care (SoC) in the treatment of ABSSSI in a community-based healthcare system. METHODS: This was a retrospective study of adult patients with ABSSSI treated with dalbavancin or SoC during a 27-month period. Patients were matched based on age and body mass index. The primary outcome was average net cost of care to the healthcare system per patient, calculated as the difference between reimbursement payments and the total cost to provide care to the patient. The secondary outcome was proportion of cases successfully treated, defined as no ABSSSI-related readmission within 30 days after the initiation of treatment. RESULTS: Of the 418 matched patients, 209 received SoC and 209 received dalbavancin. The average total cost of care per patient was greater with dalbavancin vs SoC ($4770 vs $2709, P < .0001). The average reimbursement per patient was $3084 with dalbavancin vs $2633 SoC (P = .527). The net cost, calculated as revenue minus total cost, was $1685 with dalbavancin vs $75 with SoC (P = .013). The overall treatment success rate was 74% with dalbavancin vs 85% with SoC (P = .004). CONCLUSIONS: Dalbavancin was more costly than SoC for the treatment of ABSSSI, with a higher 30-day readmission rate. Dalbavancin does not offer an economic or efficacy advantage.

A case of successful acyclovir desensitization in a bone marrow transplant patient.

INTRODUCTION: The incidence of acyclovir-induced hypersensitivity is rare. To our knowledge, there are four published case reports of oral acyclovir desensitization in adults. Evidence-based guidelines prompt the use of acyclovir for herpes simplex virus (HSV) prophylaxis and treatment. Literature on the cross-reactivity of structurally similar antiviral agents is conflicting, presenting a clinical challenge when choosing an alternative agent. This is a case of successful acyclovir desensitization in an allogeneic stem cell transplant patient. CASE REPORT: A 69-year-old female patient, diagnosed with myelodysplastic/myeloproliferative neoplasm, presented to the hospital for donor mismatch allogeneic bone marrow transplant. The patient reported acyclovir-induced angioedema while receiving treatment for non-complicated herpes zoster (shingles) infection.Management & Outcome: After the acyclovir oral desensitization was conducted in an ICU setting with 1:1 patient-nurse ratio, the patient was successfully started on acyclovir therapy, 800mg by mouth twice daily for HSV prophylaxis with no further complications. Discussion: Oral acyclovir desensitization can provide an option for HSV therapy in patients reporting severe allergy.

Training Load and Recovery in Volleyball During a Competitive Season.

ABSTRACT: Andrade, DM, Fernandes, G, Miranda, R, Reis Coimbra, D, and Bara Filho, MG. Training load and recovery in volleyball during a competitive season. J Strength Cond Res 35(4): 1082-1088, 2021-The objective of this study was to analyze the training load (TL) and recovery status (RS) of a volleyball team in different periods of the season. Fifteen male athletes participated in the study. Training load was quantified through the rate of perceived exertion of session. The total weekly TL of the preparatory period (PP), competitive period I (CPI), and competitive period II (CPII) was calculated. Total quality recovery was used to evaluate the initial and final RS. Training load was higher (p < 0.05) in PP than in CPI and CPII. The final RS was lower (p < 0.05) in PP than in CPI and CPII. There was a difference (p < 0.05) between the initial and final RS in the analyzed periods. An inverse correlation (ρ: -0.62) was observed between the TL and the initial and final difference RS in PP. In conclusion, PP in volleyball presented the highest TL, related to a greater difference between the initial and final RS.

Soft X-ray Chlorine Photolysis on Chlorobenzene Ice: An Experimental and Theoretical Study.

An experimental and theoretical study of the photoinduced homolysis of the carbon-chlorine bond in an ice matrix of chlorobenzene is presented. A condensed chlorobenzene film has been grown in situ and near edge X-ray fine structure (NEXAFS) spectra were collected after exposing the condensed film to a monochromatic photon beam centered at the 2822 eV resonant excitation of chlorine and at 2850 eV. The photoabsorption to the Cl 1s → σ* and Cl 1s → π* states has been measured and the hypothesis of free radical coupling reactions was investigated via time-dependent density functional theory (TD-DFT) and complete active space self-consistent field (CASSCF) calculations. Also, potential energy pathways to the C-Cl cleavage have been obtained at the CASSCF level to the Cl 1s → σ*, 1s → π*, and 1s → ∞ states. A strong dissociative character was only found for the Cl 1s → σ* resonance.

Serra Pelada: the first Amazonian Meteorite fall is a Eucrite (basalt) from Asteroid 4-Vesta.

Serra Pelada is the newest Brazilian eucrite and the first recovered fall from Amazonia (State of Pará, Brazil, June 29th 2017). In this paper, we report on its petrography, chemistry, mineralogy and its magnetic properties. Study of four thin sections reveals that the meteorite is brecciated, containing basaltic and gabbroic clasts, as well of recrystallized impact melt, embedded into a fine-medium grained matrix. Chemical analyses suggest that Serra Pelada is a monomict basaltic eucritic breccia, and that the meteorite is a normal member of the HED suite. Our results provide additional geological and compositional information on the lithological diversity of its parent body. The mineralogy of Serra Pelada consists basically of low-Ca pyroxene and high-Ca plagioclase with accessory minerals such as quartz, sulphide (troilite), chromite - ulvöspinel and ilmenite. These data are consistent with the meteorite being an eucrite, a basaltic achondrite and a member of the howardite-eucrite-diogenite (HED) clan of meteorites which most likely are from the crust asteroid 4 Vesta.

Towards a standardization of biomethane potential tests.

Production of biogas from different organic materials is a most interesting source of renewable energy. The biomethane potential (BMP) of these materials has to be determined to get insight in design parameters for anaerobic digesters. Although several norms and guidelines for BMP tests exist, inter-laboratory tests regularly show high variability of BMPs for the same substrate. A workshop was held in June 2015, in Leysin, Switzerland, with over 40 attendees from 30 laboratories around the world, to agree on common solutions to the conundrum of inconsistent BMP test results. This paper presents the consensus of the intense roundtable discussions and cross-comparison of methodologies used in respective laboratories. Compulsory elements for the validation of BMP results were defined. They include the minimal number of replicates, the request to carry out blank and positive control assays, a criterion for the test duration, details on BMP calculation, and last but not least criteria for rejection of the BMP tests. Finally, recommendations on items that strongly influence the outcome of BMP tests such as inoculum characteristics, substrate preparation, test setup, and data analysis are presented to increase the probability of obtaining validated and reproducible results.

A school-based intervention improves physical fitness in Ecuadorian adolescents: a cluster-randomized controlled trial.

BACKGROUND: Effective lifestyle interventions are needed to prevent noncommunicable diseases in low- and middle-income countries. We analyzed the effects of a school-based health promotion intervention on physical fitness after 28 months and explored if the effect varied with important school characteristics. We also assessed effects on screen time, physical activity and BMI. METHODS AND RESULTS: We performed a cluster-randomized pair matched trial in schools in urban Ecuador. The intervention included an individual and environmental component tailored to the local context and resources. Primary outcomes were physical fitness (EUROFIT battery), screen time (questionnaires) and physical activity (accelerometers). Change in BMI was a secondary outcome. A total of 1440 grade 8 and 9 adolescents (intervention: n = 700, 48.6%) and 20 schools (intervention: n = 10, 50%) participated. Data of 1083 adolescents (intervention: n = 550, 50.8%) from 20 schools were analyzed. CONCLUSIONS: A school-based intervention with an individual and environment component can improve physical fitness and can minimize the decline in physical activity levels from childhood into adolescence in urban Ecuador. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01004367.

Acute effect of ultramarathon on systolic and diastolic cardiac function: Systematic review and meta-analysis.

BACKGROUND: Ultramarathon running poses physiological challenges, impacting cardiac function. This systematic review and meta-analysis explore the acute effects of single-stage ultramarathon running on cardiac function. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations were followed. Searches covered Medline, Embase, CINAHL, SPORTDiscus, Web of Science, Central Cochrane, and Scopus. Random effects meta-analyses assessed left ventricular (LV) and right ventricular (RV) variables, expressed as mean differences (MD) with 95% confidence intervals (CI). RESULTS: Among 6972 studies, 17 were included. Post-ultramarathon reductions were found in LV end-diastolic diameter (LVEDD) (-1.24; 95% CI = -1.77, -0.71 mm), LV end-diastolic volume (LVEDV) (-9.92; 95% CI = -15.25, -4.60 ml), LV stroke volume (LVSV) (-8.96 ml, 95% CI -13.20, -4.72 ml), LV ejection fraction (LVEF) (-3.71; 95% CI = -5.21, -2.22%), LV global longitudinal strain (LVGLS) (-1.48; 95% CI = -2.21, -0.76%), E/A (-0.30; 95% CI = -0.38, -0.22 cm/s), .E' (-1.35 cm/s, 95% CI -1.91, -0.79 cm/s), RV fractional area change (RVFAC) (-3.34, 95% CI = -5.84, -0.84%), tricuspid annular plane systolic excursion (TAPSE) (-0.12, 95% CI = -0.22, -0.02 cm), RV global longitudinal strain (RVGLS) (-1.73, 95% CI = -2.87, -0.59%), with increases in RV end-diastolic area (RVEDA) (1.89, 95% CI = 0.63, 3.14 cm2), RV Peak A' (1.32 cm/s, 95% CI 0.20, 2.44), and heart rate (18.24, 95% CI = 15.16, 21.32). No significant differences were observed in LV end-systolic diameter (LVESD), LV end-systolic volume (LVESV), RV end-diastolic diameter (RVEDD), RV Peak E', and RV Peak S'. CONCLUSIONS: Evidence suggests immediate impairment of systolic and diastolic cardiac function post-ultramarathon running.

Low Ocular Perfusion Pressure Values at Rest and during Resistance Exercise in Offspring of Glaucoma Patients.

Purpose: To compare the ocular perfusion pressure (OPP) response during physical exercise in individuals with and without a family history (FH+, FH-) of glaucoma. Methods: Thirty-four subjects, divided into FH+ and FH- groups, realized 3 min at rest, 3 min of isometric handgrip exercise at 30% of maximal voluntary contraction, followed by 3 min of recovery. Blood pressure (Dixtal® automatic device) and intraocular pressure (Goldmann applanation tonometer) were measured during rest, exercise, and recovery. The mean OPP (mOPP) was calculated. Results: In the FH+ group (17 subjects), baseline mOPP values were significantly lower than in the FH- group (17 subjects) (right eye: P < 0.001, left eye: P < 0.001, respectively). During exercise, both the FH+ and FH- groups showed a similar increase in mOPP in both eyes (right eye: FH+: 38 ± 4 mmHg vs. 51 ± 7 mmHg, FH-: 48 ± 5 mmHg vs. 57 ± 9 mmHg, P < 0.001; left eye: FH+: 39 ± 3 mmHg vs. 51 ± 7 mmHg; FH-: 46 ± 5 mmHg vs. 58 ± 8 mmHg, P < 0.001, respectively). However, the FH+ group maintained significantly lower mOPP values compared to the FH- group in the right and left eyes (group effect: P = 0.002, P = 0.002, respectively). The percentage of increase in mOPP in the FH+ group was greater compared to the FH- group during exercise (right eye: 34.1% ± 15.9% vs. 22.1% ± 13.2%, respectively; P = 0.025; left eye: 33.2% ± 17.7% vs. 22.4% ± 13.7%, respectively, P = 0.056). Conclusions: mOPP increased during physical exercise in both groups, but the FH+ group had lower absolute values. In addition, the FH+ group appears to demonstrate a higher percentage increase in mOPP compared to the FH- group.

Treatment of chronic hepatitis C virus infection with crushed ledipasvir/sofosbuvir administered through a percutaneous endoscopic gastrostomy tube in a patient with HIV coinfection.

PURPOSE: Ledipasvir/sofosbuvir is an oral combination therapy containing fixed doses of direct-acting antiviral agents indicated for the treatment of hepatitis C virus (HCV) infection. Currently there are limited data on the clinical efficacy of crushed ledipasvir/sofosbuvir administered via feeding tube. SUMMARY: This case report discusses the successful treatment of chronic HCV genotype 1b infection with crushed ledipasvir/sofosbuvir administered through a percutaneous endoscopic gastrostomy (PEG) tube in a patient with human immunodeficiency virus (HIV) coinfection and high-grade sarcoma who had severe swallowing difficulties. The patient received crushed ledipasvir/sofosbuvir daily for a total of 12 weeks. At 12 weeks the patient had achieved a sustained virologic response. CONCLUSION: Currently, ledipasvir/sofosbuvir is available only as a tablet, with limited pharmacokinetic data available to guide clinicians on use of the fixed-dose combination medication in crushed form. This case report highlights our experience treating a patient with HCV/HIV coinfection through administration of crushed ledipasvir/sofosbuvir via PEG tube, which we found to be a safe and effective therapeutic option.

Theoretical investigation on the stability of negatively charged formic acid clusters.

Recent experimental results on negatively charged formic acid clusters generated by the impact of (252)Cf fission fragments on icy formic acid target are compared to quantum mechanical calculations. Structures for the clusters series, (HCOOH)nOH(-), where 2 < or = n < or = 4, are proposed based on ab initio electronic structure methods. The results show that cluster growth does not have a regular pattern of nucleation. A stability analysis was performed considering the commonly defined stability function. Temporal behavior of the clusters was evaluated by Born-Oppenheimer molecular dynamics to check the mechanism that provides cluster stability. The evaluated temporal profiles indicate the importance of hydrogen atom migration between the formic acid moieties in maintaining the stability of the structures and the water formation due to hydrogen abstraction by the hydroxyl approach.

Impact of Nasal Swabs on Empiric Treatment of Respiratory Tract Infections (INSERT-RTI).

Methicillin-resistant Staphylococcus aureus (MRSA) polymerase-chain-reaction nasal swabs (PCRNS) are a rapid diagnostic tool with a high negative predictive value. A PCRNS plus education "bundle" was implemented to inform clinicians on the utility of PCRNS for anti-MRSA therapy de-escalation in respiratory tract infections (RTI). The study included patients started on vancomycin with a PCRNS order three months before and after bundle implementation. The primary objective was the difference in duration of anti-MRSA therapy (DOT) for RTI. Secondary objectives included hospital length of stay (LOS), anti-MRSA therapy reinitiation, 30-day readmission, in-hospital mortality, and cost. We analyzed 62 of 110 patients screened, 20 in the preintervention and 42 in the postintervention arms. Mean DOT decreased after bundle implementation by 30.3 h (p = 0.039); mean DOT for patients with a negative PCRNS decreased by 39.7 h (p = 0.014). Median cost was lower after intervention [USD$51.69 versus USD$75.30 (p < 0.01)]. No significant difference in LOS, mortality, or readmission existed. The bundle implementation decreased vancomycin therapy and cost without negatively impacting patient outcomes.

DNA nucleobase synthesis at Titan atmosphere analog by soft X-rays.

Titan, the largest satellite of Saturn, has an atmosphere chiefly made up of N(2) and CH(4) and includes traces of many simple organic compounds. This atmosphere also partly consists of haze and aerosol particles which during the last 4.5 gigayears have been processed by electric discharges, ions, and ionizing photons, being slowly deposited over the Titan surface. In this work, we investigate the possible effects produced by soft X-rays (and secondary electrons) on Titan aerosol analogs in an attempt to simulate some prebiotic photochemistry. The experiments have been performed inside a high vacuum chamber coupled to the soft X-ray spectroscopy beamline at the Brazilian Synchrotron Light Source, Campinas, Brazil. In-situ sample analyses were performed by a Fourier transform infrared spectrometer. The infrared spectra have presented several organic molecules, including nitriles and aromatic CN compounds. After the irradiation, the brownish-orange organic residue (tholin) was analyzed ex-situ by gas chromatographic (GC/MS) and nuclear magnetic resonance ((1)H NMR) techniques, revealing the presence of adenine (C(5)H(5)N(5)), one of the constituents of the DNA molecule. This confirms previous results which showed that the organic chemistry on the Titan surface can be very complex and extremely rich in prebiotic compounds. Molecules like these on the early Earth have found a place to allow life (as we know) to flourish.

Native valve infective endocarditis due to Micrococcus luteus in a non-Hodgkin's lymphoma patient.

Micrococcus species are typically considered contaminants from skin and mucous membranes. However, especially in severely immunocompromised patients, a blood culture with Micrococcus could be the cause of a significant infection. We report a 65-year-old female with non-Hodgkin's lymphoma who developed native valve infective endocarditis due to Micrococcus luteus. There is no defined therapeutic regimen for infective endocarditis due to Micrococcus luteus; however, our patient was successfully treated for six weeks with vancomycin and rifampin. To our knowledge, there is only one other case report of native valve endocarditis due to Micrococcus luteus.

Theoretical investigation on the stability of ionic formic acid clusters.

Recent experimental results on positive charged formic acid clusters generated by the impact of (252)Cf fission fragments (FF) on icy formic acid target are examined in this paper by quantum mechanical calculations. Structures for the clusters series, (HCOOH)(n)H(+) and (HCOOH)(n)H(3)O(+), where 2 < or = n < or = 4, are proposed based on ab initio electronic structure methods. Results show that cluster growth does not present a regular pattern of nucleation. A stability analysis was performed considering the commonly defined stability function, where E is the total electronic energy plus the zero point vibrational energy correction, including the BSSE correction. The stability analysis leads to a picture that is compatible with experimental observations, indicating a decay of the stability with the increase of cluster mass. Temporal behavior of the clusters was evaluated by Born-Oppenheimer molecular dynamics to check the mechanism that provides cluster stability. The evaluated temporal profiles indicate the importance of hydrogen atom migration between the formic acid moieties to maintain the stability of the structures.

Informed consent in anesthesiology: An exploratory study / El consentimiento informado en anestesiología: un estudio exploratorio / Consentimento informado em anestesiologia: um estudo exploratório

Abstract: In the literature Informed consent (IC) assumptions is well established. However, the different stages and the conditions under which the IC for anesthetic practices is obtained, is scarce. The aim of the present study is to explore the phases and conditions of IC in anesthesiology. Anonymized clinical records of 325 patients submitted to anesthetic procedures at the Institute of Oncology of Porto were analyzed. A total agreement between the anesthetic techniques established in the IC and those performed, was reach with 270 patients. The importance of IC in clinical practice is discussed and an ideal process for IC is argued.

Resumen: El consentimiento informado (CI) está bien establecido en la literatura. Sin embargo, la información sobre las diferentes fases y condiciones en las que se obtiene el CI para las prácticas anestésicas es escasa. El objetivo del presente estudio es explorar las fases y condiciones de obtención de la CI en anestesiología. Se analizaron las historias clínicas anónimas de 325 pacientes sometidos a procedimientos anestésicos en el Instituto de Oncología de Oporto. Se alcanzó una concordancia total entre las técnicas de anestesia establecidas en el CI y las realizadas con 270 pacientes. Se defiende la importancia del CI en la práctica clínica y se discute un proceso ideal para obtenerlo.

Resumo: Na literatura o Consentimento Informado (CI) é bem estabelecido. Contudo, a informação sobre as diferentes fases e as condições em que o CI para práticas anestésicas é obtido, é escassa. O objetivo do presente estudo é explorar as fases e condições da obtenção do CI em anestesiologia. Foram analisados os registos clínicos anónimos de 325 pacientes submetidos a procedimentos anestésicos no Instituto de Oncologia do Porto. Foi alcançado um acordo total entre as técnicas anestésicas estabelecidas no CI e as realizadas, com 270 pacientes. A importância do CI na prática clínica é defendida e discute-se um processo ideal para a obtenção do CI.