Waveform analysis-guided treatment versus a standard shock-first protocol for the treatment of out-of-hospital cardiac arrest presenting in ventricular fibrillation: results of an international randomized, controlled trial.

BACKGROUND: Ventricular fibrillation (VF) waveform properties have been shown to predict defibrillation success and outcomes among patients treated with immediate defibrillation. We postulated that a waveform analysis algorithm could be used to identify VF unlikely to respond to immediate defibrillation, allowing selective initial treatment with cardiopulmonary resuscitation in an effort to improve overall survival. METHODS AND RESULTS: In a multicenter, double-blind, randomized study, out-of-hospital cardiac arrest patients in 2 urban emergency medical services systems were treated with automated external defibrillators using either a VF waveform analysis algorithm or the standard shock-first protocol. The VF waveform analysis used a predefined threshold value below which return of spontaneous circulation (ROSC) was unlikely with immediate defibrillation, allowing selective treatment with a 2-minute interval of cardiopulmonary resuscitation before initial defibrillation. The primary end point was survival to hospital discharge. Secondary end points included ROSC, sustained ROSC, and survival to hospital admission. Of 6738 patients enrolled, 987 patients with VF of primary cardiac origin were included in the primary analysis. No immediate or long-term survival benefit was noted for either treatment algorithm (ROSC, 42.5% versus 41.2%, P=0.70; sustained ROSC, 32.4% versus 33.4%, P=0.79; survival to admission, 34.1% versus 36.4%, P=0.46; survival to hospital discharge, 15.6% versus 17.2%, P=0.55, respectively). CONCLUSIONS: Use of a waveform analysis algorithm to guide the initial treatment of out-of-hospital cardiac arrest patients presenting in VF did not improve overall survival compared with a standard shock-first protocol. Further study is recommended to examine the role of waveform analysis for the guided management of VF.

Valorisation of rejected unripe plantain fruits of Musa AAB Simmonds: from nutritional characterisation to the conceptual process design for prebiotic production.

The increasing consumption of plantain fruits with specific quality standards generates high agricultural waste. This work aimed at valorising the rejected unripe pulp of Dominico-Hartón plantain fruits (Musa AAB Simmonds). The pulp was characterised physico-chemically, thermally and functionally. The data gathered experimentally and collected from different databases were used to design a production process of isomalto-oligosaccharides (IMO) syrup. The plantain flour contains high levels of starch (87 ± 2%) and amylose (31.2 ± 0.8%). The flour showed stability at high temperatures (pasting temperature of 79.26 ± 0.02 °C), allowing its use in high temperature processes. In vitro gastrointestinal digestion of the plantain flour showed that when cooked, the glycemic index of the flour increased from 47.7 ± 2.2 to 84.2 ± 1.8, while its resistant starch content only slightly decreased from 71.7 ± 1% to 52.6 ± 2%, suggesting that this type of flour preserves high content of dietary fibre after digestion. The conceptual process design showed that 24.48 g of IMO are theoretically obtained from 53.24 g of plantain flour maltose. These results suggest that the rejected plantain pulp holds high potential as an ingredient for the production of prebiotic compounds such as IMO.

Desenlaces negativos y mortalidad en el anciano frágil sometido a cirugía mayor: ¿qué factores de riesgo impactan más?

El adulto mayor, con frecuencia frágil, es un paciente susceptible a un sinnúmero de complicaciones, tanto inmediatas como a corto, mediano y largo plazo, posterior a una intervención quirúrgica. En función de las comorbilidades presentadas, se debe hacer un abordaje integral para alcanzar el mejor estado orgánico previo a la cirugía e intentar mantenerlo durante y posterior a la intervención. Considerar la fuerza estadística de los desenlaces negativos y, específicamente, de la mortalidad en adultos mayores sometidos a cirugía mayor, es verdaderamente un reto. Incluso, esto trasciende a otros campos como la bioética, al plantearse un dilema sobre la distanasia, cuando se recurre a ciertas intervenciones riesgosas en aquellos con un pronóstico de vida temeroso. Recientemente, se ha publicado evidencia interesante que ha estimado la incidencia, riesgo de mortalidad y factores asociados a desenlaces negativos en adultos mayores sometidos a cirugía mayor, planteando posibles modificaciones en los algoritmos de toma de decisiones en futuras guías de práctica clínica en cirugía. El objetivo de esta revisión consiste en analizar evidencia actualizada sobre qué factores de riesgo impactarían más sobre desenlaces negativos y mortalidad en el adulto mayor sometido a cirugía mayor. Se realizó una búsqueda bibliográfica utilizando los términos de búsqueda "Cirugía Mayor" y "Adulto Mayor", además de sinónimos, en las bases de datos PubMed, ScienceDirect, Web of Science y MEDLINE. En cirugía general y subespecialidades, es muy complejo determinar factores de riesgo precisos y extrapolables a todos los escenarios quirúrgicos, debido a la complejidad y especificidad de ciertos órganos y procedimientos. Existe evidencia sobre adultos frágiles que son sometidos a cirugía por cáncer colorrectal, metástasis hepática, cáncer de pulmón, enfermedad pancreática y cáncer esofágico, en donde se registra una mayor estancia hospitalaria; y de forma general, la mortalidad es mayor en aquellos sometidos a cirugía oncológica. No obstante, tanto la integridad física como mental se asocian con peores desenlaces, y la prehabilitación quirúrgica podría impactar de manera positiva sobre esta situación, al mejorar la reserva funcional y tiempo de recuperación posquirúrgico.

The elderly, often frail, are patients susceptible to numerous complications, both immediate and in the short, medium and long term, following surgical interventions. Depending on their comorbidities, a comprehensive approach should be taken to achieve the best condition of the organs prior to surgery and attempt to maintain it during and after the intervention. Considering the statistical strength of negative outcomes, specifically mortality in elderly patients undergoing major surgery, is truly a challenge. This even extends to other fields such as bioethics, raising a dilemma about dysthanasia when resorting to certain risky interventions in those with a fearful life prognosis. Recently, interesting evidence estimating the incidence, mortality risk and factors associated with negative outcomes in elderly patients undergoing major surgery has been published, suggesting possible modifications in decision-making algorithms for future clinical practice guidelines in surgery. The objective of this review is to analyze updated evidence on which risk factors would have the greatest impact on negative outcomes and mortality in elderly patients undergoing major surgery. A literature search was conducted using the search terms "Major Surgery" and "Elderly," in addition to synonyms, in the PubMed, ScienceDirect, Web of Science and MEDLINE databases. In general surgery and subspecialties, it is very complex to determine precise risk factors that can be extrapolated to all surgical scenarios due to the complexity and specificity of certain organs and procedures. Evidence has found that frail adults undergoing surgery for colorectal cancer, liver metastasis, lung cancer, pancreatic disease and esophageal cancer have the longest hospital stays, and overall mortality is higher in those undergoing oncologic surgery. However, both physical and mental integrity are associated with worse outcomes, and surgical prehabilitation could positively impact this situation by improving functional reserve and post-surgical recovery time.

Out-of-hospital administration of albuterol for asthma by basic life support providers.

BACKGROUND: Each year, approximately 40,000 patients with acute asthma are transported by the Fire Department of New York City (NYC) Emergency Medical Services (EMS). Out-of-hospital administration of bronchodilator therapy has, however, been restricted by scope of practice to advanced life support (ALS) providers. Since the rapid availability of ALS units cannot always be assured, some individuals with acute asthma may receive only basic life support (BLS) measures in the field. OBJECTIVES: To demonstrate that basic emergency medical technicians (EMT-Bs) are able to effectively administer nebulized albuterol to asthma patients in the out-of-hospital environment. METHODS: This was a prospective, observational cohort study of 9-1-1 asthma calls received by the NYC EMS system for patients between the ages of 1 and 65 years. Baseline peak expiratory flow rate (PEFR) and other clinical measures were obtained prior to and following BLS administration of one or two treatments with nebulized albuterol. RESULTS: Data were available for 3,351 patients over a one-year study period. One out-of-hospital albuterol treatment was given in 60%, while 40% of the patients received two. The PEFRs increased from 40.4% predicted (SD +/-21.0) to 54.8% predicted (SD +/-26.1), for a posttreatment improvement of 14.4% points (95% CI = 13.8 to 15.1). Other clinical outcome measures, including dyspnea index, respiratory rate, and use of accessory muscles, also showed improvement. CONCLUSIONS: This study demonstrates that EMT-Bs can effectively administer albuterol to acute asthma patients in the out-of-hospital environment.

MEDICIÓN DEL EQUILIBRIO LIQUIDO-VAPOR DEL SISTEMA METANOL-ACETATO DE METILO A 580 mmHg / EXPERIMENTAL LIQUID VAPOUR EQUILIBRIUM OF THE BINARY SYSTEM METHANOL-METHYL ACETATE AT 580 mmHG

En este trabajo se midió experimentalmente el equilibrio líquido vapor para el sistema binario Metanol - Acetato de Metilo a 580 mmHg. Las mediciones experimentales fueron realizadas utilizando un equipo con recirculación tipo Cottrell. Los datos obtenidos fueron comparados con los resultados adquiridos de la simulación del equilibrio líquido vapor del sistema bajo estudio. En la simulación se empleó el modelo de actividad NRTL para representar la no idealidad de la fase líquida (con parámetros encontrados en la literatura), y la ecuación de estado de Hayden O´Connel para la no idealidad de la fase vapor. De igual manera, se correlacionaron los datos para encontrar nuevos parámetros del modelo de actividad en NRTL. Además, a partir de datos experimentales medidos a 760 mmHg encontrados en la literatura para el sistema estudiado, se verificó la ley de Vresky, la cual permite sin necesidad de cálculos rigurosos predecir la dirección de desplazamiento de un azeótropo binario cunado se varía la presión del sistema.

In this work the liquid - vapor binary equilibrium for the system Methanol - Methyl Acetate was measured at 580 mmHg using equipment with recirculation that also can be employed for reactive mixtures. The obtained data was compared with liquid vapor equilibrium prediction employing NRTL activity model for the liquid phase (using parameters found in the literature) and the Hayden O´Connel's equation of state for the non ideality of vapor phase. New parameters of NRTL activity model were obtained. The Vresky law that permits without rigorous calculations to predict qualitatively the displacement of binary azeotropes by pressure changes was confirmed, using various experimental data that is reported in the literature for this system at 760 mm Hg.