Detailed stratified GWAS analysis for severe COVID-19 in four European populations.

Given the highly variable clinical phenotype of Coronavirus disease 2019 (COVID-19), a deeper analysis of the host genetic contribution to severe COVID-19 is important to improve our understanding of underlying disease mechanisms. Here, we describe an extended genome-wide association meta-analysis of a well-characterized cohort of 3255 COVID-19 patients with respiratory failure and 12 488 population controls from Italy, Spain, Norway and Germany/Austria, including stratified analyses based on age, sex and disease severity, as well as targeted analyses of chromosome Y haplotypes, the human leukocyte antigen region and the SARS-CoV-2 peptidome. By inversion imputation, we traced a reported association at 17q21.31 to a ~0.9-Mb inversion polymorphism that creates two highly differentiated haplotypes and characterized the potential effects of the inversion in detail. Our data, together with the 5th release of summary statistics from the COVID-19 Host Genetics Initiative including non-Caucasian individuals, also identified a new locus at 19q13.33, including NAPSA, a gene which is expressed primarily in alveolar cells responsible for gas exchange in the lung.

Impact of persistently high sea surface temperatures on the rhizobiomes of Zostera marina in a Baltic Sea benthocosms.

Persistently high marine temperatures are escalating and threating marine biodiversity. The Baltic Sea, warming faster than other seas, is a good model to study the impact of increasing sea surface temperatures. Zostera marina, a key player in the Baltic ecosystem, faces susceptibility to disturbances, especially under chronic high temperatures. Despite the increasing number of studies on the impact of global warming on seagrasses, little attention has been paid to the role of the holobiont. Using an outdoor benthocosm to replicate near-natural conditions, this study explores the repercussions of persistent warming on the microbiome of Z. marina and its implications for holobiont function. Results show that both seasonal warming and chronic warming, impact Z. marina roots and sediment microbiome. Compared with roots, sediments demonstrate higher diversity and stability throughout the study, but temperature effects manifest earlier in both compartments, possibly linked to premature Z. marina die-offs under chronic warming. Shifts in microbial composition, such as an increase in organic matter-degrading and sulfur-related bacteria, accompany chronic warming. A higher ratio of sulfate-reducing bacteria compared to sulfide oxidizers was found in the warming treatment which may result in the collapse of the seagrasses, due to toxic levels of sulfide. Differentiating predicted pathways for warmest temperatures were related to sulfur and nitrogen cycles, suggest an increase of the microbial metabolism, and possible seagrass protection strategies through the production of isoprene. These structural and compositional variations in the associated microbiome offer early insights into the ecological status of seagrasses. Certain taxa/genes/pathways may serve as markers for specific stresses. Monitoring programs should integrate this aspect to identify early indicators of seagrass health. Understanding microbiome changes under stress is crucial for the use of potential probiotic taxa to mitigate climate change effects. Broader-scale examination of seagrass-microorganism interactions is needed to leverage knowledge on host-microbe interactions in seagrasses.

COVID-19 outbreaks among crew members in non-cruise vessels anchoring in Salvador, Brazil, 2021.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected the maritime sector due to virus transmission onboard and traffic restrictions. However, reports of SARS-CoV-2 transmission on board have been mostly restricted to those occurring on cruise ships. OBJECTIVES: To report COVID-19 outbreaks in eight non-cruise vessels and discuss measures to prevent and control the onboard transmission of SARS-CoV-2. METHODS: We investigated outbreaks of COVID-19 on vessels anchoring in Baía de Todos-os-Santos, Salvador, Brazil, between February and November 2021. FINDINGS: Most vessels were cargo ships that had docked several times before anchoring in Salvador (five had docked in ≥ 9 ports). The crew ranged from 22 to 63 members. The infection attack rate on each vessel ranged from 9.7 to 88.9%. The risk of symptomatic infection largely varied among the crew of each vessel (0 to 91.6%). Overall, the risk of developing COVID-19 signs and symptoms was lower among crew members vaccinated (age-adjusted risk ratio: 0.19; 95% confidence interval 0.06-0.65). SARS-CoV-2 variants not previously identified in Salvador were detected (C.14, B.1.617.2 and B.1.351). MAIN CONCLUSIONS: Despite maritime guidelines to avert COVID-19 on board, outbreaks have happened. The multiple stopovers of non-cruise vessels during their routes may contribute to the spread of SARS-CoV-2 variants worldwide. Reducing the onboard transmission of SARS-CoV-2 depends on joint efforts by the crew and local health authorities and, equally important, achieving high vaccination coverage to prevent infections and illness.

Phosphorus solubility and dynamics in a tropical soil under sources derived from wastewater and sewage sludge.

Conventional phosphate fertilizers are usually highly water-soluble and rapidly solubilize when moistened by the soil solution. However, if this solubilization is not in alignment with plants demand, P can react with the soil colloidal phase, becoming less available over time. This is more pronounced in acidic, oxidic tropical soils, with high P adsorption capacity, reducing the efficiency of P fertilization. Furthermore, these fertilizers are derived from phosphate rock, a non-renewable resource, generating an environmental impact. To assess these concerns, waste-recycled P sources (struvite, hazenite and AshDec®) were studied for their potential of reducing P fixation by the soil and improving the agronomic efficiency of the P fertilization. In our work, we compared the solubilization dynamics of struvite, hazenite, AshDec® to triple superphosphate (TSP) in a sandy clay loam Ferralsol, as well as their effect on solution pH and on soil P pools (labile, moderately-labile and non-labile) via an incubation experiment. Leaching columns containing 50 g of soil with surface application of 100 mg per column (mg col-1) of P from each selected fertilizer and one control (nil-P) were evaluated for 60 days. Daily leachate samples from the column were analyzed for P content and pH. Soil was stratified in the end and submitted to P fractionation. All results were analyzed considering p < 0.05. Our findings showed that TSP and struvite promoted an acid P release reaction (reaching pHs of 4.3 and 5.5 respectively), while AshDec® and hazenite reaction was alkaline (reaching pHs of 8.4 and 8.5 respectively). Furthermore, TSP promoted the highest P release among all sources in 60 days (52.8 mg col-1) and showed rapid release dynamic in the beginning, while struvite and hazenite showed late release dynamics and lower total leached P (29.7 and 15.5 mg col-1 P respectively). In contrast, no P-release was detected in the leachate of the AshDec® over the whole trial period. Struvite promoted the highest soil labile P concentration (7938 mg kg-1), followed by hazenite (5877 mg kg-1) and AshDec® (4468 mg kg-1), all higher than TSP (3821 mg kg-1), while AshDec® showed high moderately-labile P (9214 mg kg-1), reaffirming its delayed release potential.

Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) System for Outcome Prediction in Elderly Patients Undergoing Major Vascular Surgery.

OBJECTIVE: POSSUM system is widely used and validated for 30-day mortality and morbidity prediction. The aim of this study was to evaluate the performance of five POSSUM's equations (POSSUM, P-POSSUM, V-POSSUM, V-POSSUM physiology and V-POSSUM Cambridge) on predicting 30-day mortality and morbidity in elderly patients undergoing major elective vascular surgery. DESIGN: A retrospective longitudinal cohort study. SETTING: A study conducted at an University Hospital. PARTICIPANTS: 208 elderly patients (≥ 60 years) undergoing major elective vascular surgery. MEASUREMENTS: Data collected from the clinical files included patient's characteristics, diagnosis, surgery, comorbidities, parameters from POSSUM score, 30, 60 and 90-day mortality and 30-day morbidity. POSSUM system's goodness-of-fit for predicting mortality and morbidity was assessed by Hosmer-Lemeshow test (H-L T) and Standardized Mortality/Morbidity Ratio (SMR) and discriminative ability by the area under the ROC curves (ROC-AUC). Patients' average age was 70.8 years, 81% males. INTERVENTIONS: None. MAIN RESULTS: The overall 30-day mortality rate was 2.97% (n=6) and 30-day morbidity was 29.2% (n=59). POSSUM, P-POSSUM, V-POSSUM, V-POSSUM physiology and V-POSSUM Cambridge equation predicted an overall of 29.1, 4.43, 15.3, 21.9 and 13.5 deaths, respectively. POSSUM morbidity equation predicted 105.0 complications. H-LT p-values were 0.001, 0.164, 0.208, 0.011, 0.331 and <0.001, respectively. SMRs and 95% confidence interval (CI) were 0.21[0.04-0.37], 1.35[0.27-2.44], 0.39[0.08-0.71], 0.27[0.06-0.49], 0.44[0.09-0.80] and 0.56[0.42-0.71], respectively. ROC-AUC and 95% CI were 0.72[0.49-0.95], 0.72[0.49-0.95], 0.73[0.51-0.94], 0.69[0.50-0.89], 0.72[0.52-0.92] and 0.71[0.63-0.79], respectively. CONCLUSIONS: P-POSSUM had the best performance predicting 30-day mortality. All the other overestimated 30-day mortality. Prediction of morbidity was inadequate. POSSUM scoring models may not be robust tools for risk prediction in elderly patients undergoing major elective vascular surgery and need further calibration and discrimination.

Solvatochromic parameters of deep eutectic solvents formed by ammonium-based salts and carboxylic acids.

Deep eutectic solvents (DES) have been studied in a wide range of applications, and despite their potential as sustainable solvents, detailed knowledge on their solvatochromic parameters is still lacking. To overcome this problem, in this work, the Kamlet Taft (KT) solvatochromic parameters, namely the hydrogen-bond acidity, hydrogen-bond basicity and dipolarity/polarizability, of a wide range of DES composed of ammonium-based salts as hydrogen bond acceptors (HBAs), and carboxylic acids as hydrogen bond donors (HBDs), were determined aiming at better understanding the influence of the chemical structure of the DES components on their polarity. It is shown that the high acidity of the DES investigated is mainly provided by the organic acid present in the mixture, and that an increase of the alkyl side chain of both the HBA and the HBD species leads to a lower ability of the solvent to donate protons. On the other hand, the ammonium salt plays the major role on the hydrogen-bond basicity of DES. Contrarily to the hydrogen-bond acidity, an increase in the length of the aliphatic moieties of both the carboxylic acid and salt cation results in solvents with higher ability to accept protons. The dipolarity/polarizability of DES is mainly defined by the ionic species present, and tend to decrease with the increase of the aliphatic moiety of the organic acid. In general, DES composed of ammonium-based salts and carboxylic acids present a higher capacity to donate and accept protons when compared to most of the ionic liquids or organic molecular solvents.

Solubility and solvation of monosaccharides in ionic liquids.

Herein, solubility experimental data for six monosaccharides, viz.d-(+)-glucose, d-(+)-mannose, d-(-)-fructose, d-(+)-galactose, d-(+)-xylose and l-(+)-arabinose, in four ionic liquids (ILs), at temperatures ranging from 288.2 to 348.2 K, were obtained aimed at gathering a better understanding of their solvation ability and molecular-level mechanisms which rule the dissolution process. To ascertain the chemical features that enhance the solubility of monosaccharides, ILs composed of dialkylimidazolium or tetraalkylphosphonium cations combined with the dicyanamide, dimethylphosphate or chloride anions were investigated. It was found that the ranking of the solubility of monosaccharides depends on the IL; yet, d-(+)-xylose is always the most soluble while d-(-)-fructose is the least soluble monosaccharide. The results obtained show that both the IL cation and the anion play a major role in the solubility of monosaccharides. Finally, from the determination of the respective thermodynamic properties of solution, it was found that enthalpic contributions are dominant in the solubilization process. However, the observed differences in the solubilities of monosaccharides in 1-butyl-3-methylimidazolium dicyanamide are ruled by a change in the entropy of solution.

Solid-liquid equilibria of binary mixtures of fluorinated ionic liquids.

Within ionic liquids, fluorinated ionic liquids (FILs) present unique physico-chemical properties and potential applications in several fields. However, the melting point of these neoteric compounds is usually higher due to the presence of fluorine atoms. This drawback may be resolved by, for instance, mixing different FILs to create eutectic mixtures. In this work, binary mixtures of fluoro-containing and fluorinated ionic liquids were considered with the aim of decreasing their melting temperatures as well as understanding and characterizing these mixtures and their phase transitions. Five FILs were selected, allowing the investigation of four binary mixtures, each of them with a common ion. Their solid-liquid and solid-solid equilibria were studied by differential scanning calorimetry and the non-ideality of the mixtures was investigated. Overall, a variety of solid-liquid equilibria with systems exhibiting eutectic behavior, polymorphs with solid-solid phase transitions, and the formation of intermediate compounds and solid solutions were surprisingly found. In addition to these intriguing behaviours, novel FILs with lower melting temperatures were obtained by the formation of binary systems, thus enlarging the application range of FILs at lower temperatures.

Teaching communication skills in clinical settings: comparing two applications of a comprehensive program with standardized and real patients.

BACKGROUND: Communication is important for the quality of clinical practice, and programs have been implemented to improve healthcare providers' communication skills. However, the consistency of programs teaching communication skills has received little attention, and debate exists about the application of acquired skills to real patients. This study inspects whether (1) results from a communication program are replicated with different samples, and (2) results with standardized patients apply to interviews with real patients. METHODS: A structured, nine-month communication program was applied in two consecutive years to two different samples of healthcare professionals (25 in the first year, 20 in the second year). Results were assessed at four different points in time, each year, regarding participants' confidence levels (self-rated), basic communication skills in interviews with standardized patients, and basic communication skills in interviews with real patients. Data were analyzed using GLM Repeated-Measures procedures. RESULTS: Improvements were statistically significant in both years in all measures except in simulated patients' assessment of the 2008 group. Differences between the two samples were non-significant. Differences between interviews with standardized and with real patients were also non-significant. CONCLUSIONS: The program's positive outcomes were replicated in different samples, and acquired skills were successfully applied to real-patient interviews. This reinforces this type of program structure as a valuable training tool, with results translating into real situations. It also adds to the reliability of the assessment instruments employed, though these may need adaptation in the case of real patients.

Template-specific optimization of NGS genotyping pipelines reveals allele-specific variation in MHC gene expression.

Using high-throughput sequencing for precise genotyping of multi-locus gene families, such as the major histocompatibility complex (MHC), remains challenging, due to the complexity of the data and difficulties in distinguishing genuine from erroneous variants. Several dedicated genotyping pipelines for data from high-throughput sequencing, such as next-generation sequencing (NGS), have been developed to tackle the ensuing risk of artificially inflated diversity. Here, we thoroughly assess three such multi-locus genotyping pipelines for NGS data, the DOC method, AmpliSAS and ACACIA, using MHC class IIß data sets of three-spined stickleback gDNA, cDNA and "artificial" plasmid samples with known allelic diversity. We show that genotyping of gDNA and plasmid samples at optimal pipeline parameters was highly accurate and reproducible across methods. However, for cDNA data, the gDNA-optimal parameter configuration yielded decreased overall genotyping precision and consistency between pipelines. Further adjustments of key clustering parameters were required tο account for higher error rates and larger variation in sequencing depth per allele, highlighting the importance of template-specific pipeline optimization for reliable genotyping of multi-locus gene families. Through accurate paired gDNA-cDNA typing and MHC-II haplotype inference, we show that MHC-II allele-specific expression levels correlate negatively with allele number across haplotypes. Lastly, sibship-assisted cDNA-typing of MHC-I revealed novel variants linked in haplotype blocks, and a higher-than-previously-reported individual MHC-I allelic diversity. In conclusion, we provide novel genotyping protocols for the three-spined stickleback MHC-I and -II genes, and evaluate the performance of popular NGS-genotyping pipelines. We also show that fine-tuned genotyping of paired gDNA-cDNA samples facilitates amplification bias-corrected MHC allele expression analysis.

Factors associated with homicides of women in Brazil, by race or colour, 2016-2020. / Fatores associados ao homicídio de mulheres no Brasil, segundo raça/cor, 2016-2020.

This ecological, time-trend study examined rates of homicide against women residing in Brazil, by state and race/colour, from 2016 to 2020, by performing. Multiple analysis by regression model on longitudinal data. During the study period, 20,405 homicides of women were recorded in Brazil. Standardised homicides rates were higher among black women (6.1/100,000) than among white women (3.4/100,000). From 2016 to 2020, rates decreased 25.2%, from 4.7 deaths per 100,000 women in 2016 to 3.5 in 2020, with a statistically significant downward trend among both black and white women. Statistically significant inverse relationships were found between female homicide rates and HDI, illiteracy rate and proportion of ill-defined causes. The average homicide rate decreased in 2019 and 2020, as compared with 2016. Despite the decreasing time trend in homicide rates for both black and white women, they differed substantially by race, with worse outcomes for black women.

O objetivo deste estudo é avaliar as taxas de homicídios contra mulheres residentes no Brasil, segundo unidades da federação e raça/cor, no período de 2016 a 2020. Trata-se de um estudo ecológico de tendência temporal. Foi realizada análise múltipla adotando-se modelo de regressão para dados longitudinais. No período, ocorreram no Brasil 20.405 homicídios de mulheres e as taxas padronizadas mostraram que as mulheres negras (6,1/100.000) apresentaram as maiores taxas, em comparação às brancas (3,4/100.000). O Brasil apresentou queda de 25,2% de 2016 a 2020. A taxa de homicídio variou de 4,7 mortes por 100 mil mulheres em 2016 para 3,5 em 2020, mas a tendência decrescente e estatisticamente significante foi observada nas taxas de mulheres negras e brancas. As variáveis IDH, taxa de analfabetismo e proporção de causas mal definidas apresentaram uma relação inversa e estatisticamente significante com as taxas de homicídio de mulheres. Nos anos de 2019 e 2020 houve uma diminuição da taxa média de homicídio em relação ao ano de 2016. Apesar do decrescimento na evolução temporal das taxas para negras e brancas, houve diferenças raciais importantes nos homicídios de mulheres, com piores resultados para as mulheres negras.

Teeth Damage during General Anesthesia.

INTRODUCTION: Dental injuries during anesthesia, especially when advanced airway management is required, represent a legal problem. Factors such as poor dental condition and excessive pressure during intubation contribute to dental damage. The maxillary central incisors are commonly affected. OBJECTIVE: The objective of this review is to know the incidence of dental injuries in adults undergoing anesthesia that requires airway management. MATERIALS AND METHODS: The search was performed in MEDLINE (through Pubmed), ClinicalTrials.gov, Scopus, LILACS (through the Virtual Health Library Regional Portal), and SciELO for all available literature on the subject up to December 2022. Inclusion criteria involved articles that studied patients aged 18 years or older who underwent general anesthesia requiring airway management with tracheal intubation or insertion of a laryngeal mask airway. RESULTS: Of all the articles, nine report dental injury associated with the type of airway management. Only one article does not have dental injury. DISCUSSION: This study addresses dental injuries related to tracheal intubation during general anesthesia. Although techniques are used to prevent them, these injuries still occur. Laryngoscopy, especially with support on the upper central incisors, can cause damage to the teeth. CONCLUSIONS: It is important that the anesthesiologist is aware of dental trauma and that orotracheal intubation or the placement of the laryngeal mask airway is performed systematically and rigorously, always considering the patient's dentition to choose the best approach in each specific situation.

Infected Spinal Hematoma After Accidental Exteriorization of an Epidural Catheter: A Case Report.

Optimal treatment and outcome after spinal hematoma remain unclear. Close neurological monitoring is the key to successful treatment. Here, we present a case of an infected spinal hematoma management. We report the case of a 51-year-old male patient, American Society of Anesthesiologists physical status I, admitted to a level I hospital due to right lower limb necrotizing fasciitis. A lumbar epidural catheter was placed for pain control without complications. On the 26th day of hospitalization, three hours after the accidental exteriorization of the epidural catheter, the patient developed severe back pain not relieved by systemic analgesia. Prophylactic low-molecular-weight heparin had been administered less than six hours before. The patient had inflammatory signs and digital pressure pain at the catheter insertion site and a positive Brudzinski sign. Sensory-motor deficits were never felt. An urgent dorsolumbar MRI exhibited a significant hematic collection at the subdural and anterior epidural level, and an infected epidural hematoma was assumed. Empirical antibiotics and hourly monitoring of sensory-motor deficits, meningeal signs, and fever were initiated. The patient remained on absolute bed rest. Low-molecular-weight heparin was stopped. The pain disappeared on the third day after the MRI. Citrobacter koseri was isolated. A re-evaluation CT scan did not show spinal compression. The patient was discharged on the 27th day after an MRI in an asymptomatic condition and was referred to acute pain consultation. Neurological deficits are usually expected at the time of spinal hematoma diagnosis. However, the classic triad of pain, sensory deficits, and motor deficits is only seen in less than half of patients. Our patient only developed severe lumbar pain. In selected cases, diagnostic MRI associated with tight monitoring and conservative management can be applied.

Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 3. Suicide prevention hotlines.

Crisis hotlines are direct communication systems, usually telephone-based, set up to prevent suicide. However, few studies have evaluated their effectiveness. The present study aims to perform a systematic review, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, of the effectiveness of interventions through direct communication systems to reduce the number of suicides or suicide attempts. We searched the MEDLINE, Cochrane, SciELO, and ClinicaTrials.gov databases, and used the 2011 Oxford Centre for Evidence-Based Medicine Levels of Evidence classification. The literature search yielded 267 studies, of which 35 fulfilled the selection criteria. Although significant heterogeneity was found among studies, there is evidence that direct telephone interventions are effective when included in broader preventive protocols and provided by trained staff. Despite the limitations, which included heterogeneity of samples, designs, and outcome measures, we were able to design a protocol for the use of remote services to prevent suicide and suicide attempts. A hotline or similar system could be an effective intervention for broader suicide prevention programs. However, further research is necessary to specify which protocol components are key to enhance effectiveness.

Recent Myocardial Infarction and Acute Heparin-Induced Thrombocytopenia: A Case Report on Perioperative Management of a Patient for Acute Limb Vascular Surgery.

The optimal alternative anticoagulation regimen for patients with heparin-induced thrombocytopenia (HIT) who need surgical procedures that involve higher levels of anticoagulation, usually performed under heparin, is not yet established. Argatroban has been reported as a safe alternative. Plasma levels and their anticoagulant effects follow a predictable profile. Also, it is easily monitored and its pharmacokinetic profile makes it suitable for patients with renal failure, as it undergoes hepatic elimination. However, its use as a substitute for heparin in HIT patients is not well-documented, especially in vascular surgery. We present a case of a successfully managed patient with acute HIT undergoing limb vascular surgery using anticoagulation with argatroban.

Beyond the Pericapsular Nerve Group (PENG) Block: A Narrative Review.

The pericapsular nerve group block shows promising results in providing pain relief with a potential motor-sparing effect in hip fracture patients. In this narrative review, we analyze the published articles, and we describe the structures achieved when performing the block. We conducted a literature search to identify the articles performing the pericapsular nerve group block, in the adult or paediatric population, from November 1, 2018, to May 15, 2021. Of the 68 selected articles, 38 were considered eligible, including 1 double-blinded randomized comparative trial, 4 observational studies, and 33 case series and case reports. The technique was described in both acute and chronic pain settings, mainly performed as single shot. All studies described effective analgesia. Quadriceps weakness was experienced in some patients. It has been described as easy to perform and has a low rate of complications. It lacks, however, adequately powered randomized controlled trials to assess its clinical value and efficacy.

Permeable spaces between glenohumeral ligaments as potential gateways for rapid regional anesthesia of the shoulder.

Shoulder pain is a highly prevalent condition, often resulting in major life limitations, and requiring effective treatments. In this work, we explore the anatomical basis of a proposed approach to the regional anesthesia of the shoulder through a single injection under the subscapularis muscle. Bilateral experimental injections in shoulders from body donors (Radiolar ® and Methylene-Blue) under the subscapular muscle (n = 11) and cadaveric systematic dissections of other 35 shoulders from body donors were performed. Injectate spread was then qualitatively assessed. Long axis of permeable foramina in the anterior aspect of the shoulder joint capsule was measured in centimeters using a digital caliper. More than 40% of specimens had at least one permeable space (Weitbrech and/or Rouvière foramina) communicating the subscapular bursa and the articular space. We further demonstrate that an ultrasonography-guided injection under the subscapularis muscle allows the spread of the injectate through the anterior, inferior and posterodorsal walls of the articular capsule, the subacromial bursa, and the bicipital groove, as well as into the articular space for some injections. The odds of accidental intraarticular injection decrease when injecting with low volumes. This anatomical study provides a detailed description of foramina between glenohumeral ligaments. Furthermore, the data shown in this work supports, as a proof of concept, a safe alternative for rapid and specific blockade of terminal sensory branches innervating the shoulder joint capsule.

Brazilian Psychiatric Association Consensus for the Management of Acute Intoxication. General management and specific interventions for drugs of abuse.

OBJECTIVE: To present the Brazilian Psychiatric Association's Consensus for the Management of Acute Intoxication. METHODS: A group of experts selected by the Brazilian Psychiatric Association searched for articles in the MEDLINE (by PubMed) and Cochrane Database, limited to human studies and acute intoxication. Groups reviewed these materials for appropriateness to the topic and the quality of the work. To perform a table of agreed recommendations at the end of the systematic review, a survey using the Delphi method was conducted. Three survey rounds were conducted to develop a consensus. RESULTS: Support for intoxication may start with Initial Management: Resuscitation/Life Support/Differential Diagnosis. For that, the group proposed these orders of assessment: A (airway), B (breathing), C (circulation), D.1. (disability), D.2. (differential diagnosis), D.3. (decontamination), D.4. (drug antidotes), E (enhanced elimination). Then, the group of experts presented specific interventions for the main drugs of abuse. CONCLUSIONS: The approach to intoxication with drugs of abuse is complex and requires systematic protocols. The group of experts suggested the adoption of the classic use in welcoming the patient of the A-B-C-D-E technique with constant investigation of this patient until reaching a specific conduct and with the support to remit the picture. The group of experts believes that this document, at this time, can help psychiatric, general, and emergency doctors deal with psychiatric emergency episodes due to acute intoxication.