Adaptation, implementation, and mixed methods evaluation of an interprofessional modular clinical practice guideline for delirium management on an inpatient palliative care unit.

BACKGROUND: Using delirium clinical guidelines may align interprofessional clinical practice and improve the care of delirious patients and their families. The aim of this project was to adapt, implement and evaluate an interprofessional modular delirium clinical practice guideline for an inpatient palliative care unit. METHODS: The setting was a 31-bed adult inpatient palliative care unit within a university-affiliated teaching hospital. Participants for the evaluation were interprofessional team members. Using integration of guideline adaptation and an education initiative, an interprofessional guideline adaptation group developed a face-to-face 'starter kit' module and four online self-learning modules. The mixed methods evaluation comprised pre-and post-implementation review of electronic patient records, an online survey, and analysis of focus groups/ interviews using an iterative, inductive thematic analysis approach. RESULTS: Guideline implementation took 12 months. All palliative care unit staff attended a 'starter kit' session. Overall completion rate of the four e-Learning modules was 80.4%. After guideline implementation, nursing documentation of non-pharmacological interventions occurring before medication administration was observed. There was 60% less scheduled antipsychotic use and an increase in 'as needed' midazolam use. The online survey response rate was 32% (25/77). Most participants viewed the guideline's implementation favourably. Six key themes emerged from the qualitative analysis of interviews and focus groups with ten participants: prior delirium knowledge or experiences, challenges of facilitating change, impacts on practice, collaborative effort of change, importance of standardized guidelines, and utility of guideline elements. CONCLUSIONS: Guideline implementation warrants concerted effort, time, and management support. Interprofessional team support facilitates the modular approach of guideline adaptation and implementation, leading to a change in clinical practice.

Ammonia and greenhouse emissions from cow's excreta are affected by feeding system, stage of lactation and sampling time.

Decomposition of dairy cows' excreta on housing floor leads to ammonia and greenhouse gases production, yet factors affecting total emissions have not been fully disclosed. This work aimed to assess the impact of lactation stage, feeding system and sampling time on gaseous emission potential of cow's faeces and urine in laboratory chambers systems. Individual faeces and urine were collected from two groups of four cows, at peak and post peak lactation, from three commercial farms with distinct feeding systems: total mixed ration (TMR), total mixed ration plus concentrate at robot (TMR + robot), and total mixed ration plus concentrate in automatic feeders (TMR + AF). Samples were collected before a.m. (T8h), at middle day (T12h), and before p.m. (T17h) milking. In a laboratory chambers system, faeces and urine were mixed in a ratio of 1.7:1, and ammonia and greenhouse gases emissions were monitored during 48-h. Cumulative N-N2O emissions were the highest in TMR + robot system, post peak cows and sampling time T17h. An interaction between stage of lactation and sampling time was detected for N-NH3 and N-N2O (g/kg organic soluble N) emissions. Post peak cows also produced the highest cumulative N-NH3 emissions. Overall results contribute for the identification of specific on-farm strategies to reduce gaseous emissions from cows' excreta.

Melatonin to prevent delirium in patients with advanced cancer: a double blind, parallel, randomized, controlled, feasibility trial.

BACKGROUND: Delirium is highly problematic in palliative care (PC). Preliminary data indicate a potential role for melatonin to prevent delirium, but no randomized controlled trials (RCTs) are reported in PC. METHODS: Patients aged ≥18 years, with advanced cancer, admitted to an inpatient Palliative Care Unit (PCU), having a Palliative Performance Scale rating ≥ 30%, and for whom consent was obtained, were included in the study. Patients with delirium on admission were excluded. The main study objectives were to assess the feasibility issues of conducting a double-blind RCT of exogenous melatonin to prevent delirium in PC: recruitment, retention, procedural acceptability, appropriateness of outcome measures, and preliminary efficacy and safety data. Study participants were randomized in a double-blind, parallel designed study to receive daily melatonin 3 mg or placebo orally at 21:00 over 28 days or less if incident delirium, death, discharge or withdrawal occurred earlier. Delirium was diagnosed using the Confusion Assessment Method. Efficacy endpoints in the melatonin and placebo groups were compared using time-to-event analysis: days from study entry to onset of incident delirium. RESULTS: Over 16 months, 60/616 (9.7%; 95% CI: 7.5-12.4%) screened subjects were enrolled. The respective melatonin (n = 30) vs placebo (n = 30) outcomes were: incident delirium in 11/30 (36.7%; 95%CI: 19.9-56.1%) vs 10/30 (33%; 95% CI: 17.3-52.8%); early discharge (6 vs 5); withdrawal (6 vs 3); death (0 vs 1); and 7 (23%) vs 11 (37%) reached the 28-day end point. The 25th percentile time-to-event were 9 and 18 days (log rank, χ2 = 0.62, p = 0.43) in melatonin and placebo groups, respectively. No serious trial medication-related adverse effects occurred and the core study procedures were acceptable. Compared to those who remained delirium-free during their study participation, those who developed delirium (n = 21) had poorer functional (p = 0.036) and cognitive performance (p = 0.013), and in particular, poorer attentional capacity (p = 0.003) at study entry. CONCLUSIONS: A larger double-blind RCT is feasible, but both subject accrual and withdrawal rates signal a need for multisite collaboration. The apparent trend for shorter time to incident delirium in the melatonin group bodes for careful monitoring in a larger trial. TRIAL REGISTRATION: Registered on July 21st 2014 with ClinicalTrials.gov : NCT02200172 .

Exercise capacity of cirrhotic patients with hepatopulmonary syndrome.

INTRODUCTION: Hepatopulmonary syndrome (HPS) is characterized by a clinical triad of liver disease and/or portal hypertension, intrapulmonary vascular dilatation and abnormal arterial oxygenation. These conditions can worsen muscle strength, exercise capacity and functionality in the affected population. OBJECTIVE: The objective of this study was to compare exercise capacity, functional condition and respiratory muscle strength in cirrhotic patients diagnosed with HPS and cirrhotic patients without this diagnosis. MATERIAL AND METHODS: This cross-sectional study used a convenience sample consisting of 178 patients (92 patients with HPS and 86 patients without HPS) with a diagnosis of liver cirrhosis caused by either alcohol consumption or the hepatitis C virus (HCV). Peak oxygen consumption (VO2 peak) was used to verify exercise capacity, the six-minute walk test (6MWT) was used to test functionality, and manovacuometry was used to evaluate the strength of the respiratory muscles. The Kolmogorov-Smirnov test and Student's t-test were used for the statistical analysis. The data were analyzed using SPSS 16.00, and p < 0.05 was considered significant. RESULTS: The group of patients with the diagnosis of HPS exhibited a lower VO2 peak (14.2 ± 2.3 vs. 17.6 ± 2.6, p < 0.001), shorter distance walked in the 6MWT (340.8 ± 50.9 vs. 416.5 ± 91.4, p < 0.001), lower maximal inspiratory pressure (-49.1 ± 9.8 vs. -74.2 ± 13.9, p = 0.001) and lower maximum expiratory pressure (60.1 ± 12.2 vs. 76.8 ± 14.7, p = 0.001). CONCLUSION: The group of cirrhotic patients diagnosed with HPS exhibited lower values for VO2 peak, distance walked in the 6MWT and respiratory muscle strength than the cirrhotic patients not diagnosed with HPS.

The Richmond Agitation-Sedation Scale modified for palliative care inpatients (RASS-PAL): a pilot study exploring validity and feasibility in clinical practice.

BACKGROUND: The Richmond Agitation-Sedation Scale (RASS), which assesses level of sedation and agitation, is a simple observational instrument which was developed and validated for the intensive care setting. Although used and recommended in palliative care settings, further validation is required in this patient population. The aim of this study was to explore the validity and feasibility of a version of the RASS modified for palliative care populations (RASS-PAL). METHODS: A prospective study, using a mixed methods approach, was conducted. Thirteen health care professionals (physicians and nurses) working in an acute palliative care unit assessed ten consecutive patients with an agitated delirium or receiving palliative sedation. Patients were assessed at five designated time points using the RASS-PAL. Health care professionals completed a short survey and data from semi-structured interviews was analyzed using thematic analysis. RESULTS: The inter-rater intraclass correlation coefficient range of the RASS-PAL was 0.84 to 0.98 for the five time points. Professionals agreed that the tool was useful for assessing sedation and was easy to use. Its role in monitoring delirium however was deemed problematic. Professionals felt that it may assist interprofessional communication. The need for formal education on why and how to use the instrument was highlighted. CONCLUSION: This study provides preliminary validity evidence for the use of the RASS-PAL by physicians and nurses working in a palliative care unit, specifically for assessing sedation and agitation levels in the management of palliative sedation. Further validity evidence should be sought, particularly in the context of assessing delirium.

Implications of seasonal and daily variation on methane and ammonia emissions from naturally ventilated dairy cattle barns in a Mediterranean climate: A two-year study.

Seasonal and daily variations of gaseous emissions from naturally ventilated dairy cattle barns are important figures for the establishment of effective and specific mitigation plans. The present study aimed to measure methane (CH4) and ammonia (NH3) emissions in three naturally ventilated dairy cattle barns covering the four seasons for two consecutive years. In each barn, air samples from five indoor locations were drawn by a multipoint sampler to a photoacoustic infrared multigas monitor, along with temperature and relative humidity. Milk production data were also recorded. Results showed seasonal differences for CH4 and NH3 emissions in the three barns with no clear trends within years. Globally, diel CH4 emissions increased in the daytime with high intra-hour variability. The average hourly CH4 emissions (g h-1 livestock unit-1 (LU)) varied from 8.1 to 11.2 and 6.2 to 20.3 in the dairy barn 1, from 10.1 to 31.4 and 10.9 to 22.8 in the dairy barn 2, and from 1.5 to 8.2 and 13.1 to 22.1 in the dairy barn 3, respectively, in years 1 and 2. Diel NH3 emissions highly varied within hours and increased in the daytime. The average hourly NH3 emissions (g h-1 LU-1) varied from 0.78 to 1.56 and 0.50 to 1.38 in the dairy barn 1, from 1.04 to 3.40 and 0.93 to 1.98 in the dairy barn 2, and from 0.66 to 1.32 and 1.67 to 1.73 in the dairy barn 3, respectively, in years 1 and 2. Moreover, the emission factors of CH4 and NH3 were 309.5 and 30.6 (g day-1 LU-1), respectively, for naturally ventilated dairy cattle barns. Overall, this study provided a detailed characterization of seasonal and daily gaseous emissions variations highlighting the need for future longitudinal emission studies and identifying an opportunity to better adequate the existing mitigation strategies according to season and daytime.

The development of an instrument that can identify children with palliative care needs: the Paediatric Palliative Screening Scale (PaPaS Scale): a qualitative study approach.

BACKGROUND: The introduction of paediatric palliative care and referral to specialised teams still occurs late in the illness trajectory of children with life-limiting diseases. The aim of this ongoing multipart study was to develop a screening instrument for paediatricians that would improve the timely identification of children who could benefit from a palliative care approach. METHODS: We used a qualitative study approach with semi-structured interviews (Part 1) and a focus group discussion (Part 2) to define the domains and items of the screening instrument. Seven international paediatric palliative care experts from the UK, France, USA, and Canada took part in face-to-face interviews, and eleven paediatric health professionals from the University Children's Hospital, Zurich, participated in a subsequent focus group discussion. RESULTS: This preliminary phase of development and validation of the instrument revealed five domains relevant to identifying children with life-limiting diseases, who could benefit from palliative care: 1) trajectory of disease and impact on daily activities of the child; 2) expected outcome of disease-directed treatment and burden of treatment; 3) symptom and problem burden; 4) preferences of patient, parents or healthcare professional; and 5) estimated life expectancy. Where palliative care seems to be necessary, it would be introduced in a stepwise or graduated manner. CONCLUSIONS: This study is a preliminary report of the development of an instrument to facilitate timely introduction of palliative care in the illness trajectory of a severely ill child. The instrument demonstrated early validity and was evaluated as being a valuable approach towards effective paediatric palliative care.

Vasopressors improve outcomes in autologous free tissue transfer: A systematic review and meta-analysis.

BACKGROUND: Vasopressor use in patients undergoing autologous free tissue transfer is generally discouraged by surgeons perioperatively. This stems from concerns about the increased risk of flap failure with their use. The aim of this systematic review was to investigate the evidence and quantify any harm or benefits associated with vasopressor use. METHODS: A systematic review of the literature was undertaken using OVID Medline to search 13 databases. The search strategy used Boolean operators, text word searches, truncation symbols, and adjacency searching. Terms such as "free flap," "free tissue graft," and "free tissue transfer" were used along with a list of appropriate vasopressors. The primary outcome was free flap failure, on which a meta-analysis was performed. RESULT: The search initially identified 1029 unique articles, which after title and abstract screening was reduced to 112, of which 15 remained after full-text screening for inclusion in the review and analysis. We analyzed data from 8427 flaps, with 6695 having received a vasopressor. Meta-analysis demonstrated that vasopressor use reduced the relative risk (RR) of free flap failure (RR: 0.70; 95% CI: 0.50-0.97; p = 0.03) but did not affect rates of other adverse events (RR: 0.81; 95% CI: 0.63-1.05; p = 0.11). CONCLUSION: Vasopressor use appears beneficial for autologous free tissue transfer, with evidence that it reduced the risk of flap failure without impacting the rates of other adverse events. The use of vasopressors should, therefore, be encouraged on a case-by-case basis, depending upon the general physiological needs of the patient.

Evaluation of biomass production, carotenoid level and antioxidant capacity produced by Thermus filiformis Using fractional factorial design.

A fractional factorial design 2(5-1) was used to evaluate the effect of temperature, pH, and concentrations of yeast extract, tryptone and Nitsch's trace elements on the biomass, total carotenoids and protection against singlet oxygen by carotenoid extracts of the bacterium Thermus filiformis. In addition, the carotenoid composition was determined by high-performance liquid chromatography connected to a diode array and mass spectrometer detectors (HPLC-DAD-MS/MS). The production of biomass ranged from 0.113 to 0.658 g/L, the total carotenoid from 137.6 to 1,517.4 µg/g and the protection against singlet oxygen from 4.3 to 85.1 %. Results of the fractional factorial design showed that temperature had a negative effect on biomass production and a positive effect on carotenoid content and protection against singlet oxygen, besides, high levels of pH value, concentrations of yeast extract and tryptone had a positive effect on biomass production only at lower temperatures. The main carotenoids of T. filiformis were thermozeaxanthins. In the tested conditions, changes in the levels of the variables influenced the biomass, carotenoid production, and protection against singlet oxygen, although they did not influence the carotenoid profile. The results of this study provide a better understanding on the interactions among certain nutritional and cultivation conditions of a thermophile bacterium, Thermus filiformis, on biomass and carotenoid amounts, as well as on the antioxidant capacity.

Mycobiota of cocoa: from farm to chocolate.

The present work was carried out to study the mycobiota of cocoa beans from farm to chocolate. Four hundred and ninety-four samples were analyzed at various stages of cocoa processing: (i) primary stage at the farm (fermentation, drying, and storage), (ii) secondary stage at processing (testa, nibs, liquor, butter, cake and powder) and (iii) the final chocolate product (dark, milk, white and powdered) collected from retail outlets. Direct plating or dilution plating on Dichloran 18% Glycerol agar were used for cocoa beans and processed product analyses, respectively. Fungi were isolated and identified using different keys of identification. The largest numbers and diversity of fungi were observed in the samples collected at the farm, especially during drying and storage. The species with the highest occurrence among samples were: Absidia corymbifera, Aspergillus sp. nov., A. flavus, Penicillium paneum and yeasts. A total of 1132 potentially toxigenic fungi were isolated from the following species or species groups: A. flavus, Aspergillus parasiticus, Aspergillus nomius, Aspergillus niger group, Aspergillus carbonarius and Aspergillus ochraceus group. The highest percentage of toxigenic fungi was found at the drying and storage stages. The industrial processing reduced the fungal contamination in all fractions and no fungi were found in the final chocolate products. The knowledge of which fungi are dominant at each processing stage of cocoa provides important data about their ecology. This understanding leads to a reduction in fungal spoilage and mycotoxin production in this product.

Assessment of potato peel and agro-forestry biochars supplementation on in vitro ruminal fermentation.

BACKGROUND: The awareness of environmental and socio-economic impacts caused by greenhouse gas emissions from the livestock sector leverages the adoption of strategies to counteract it. Feed supplements can play an important role in the reduction of the main greenhouse gas produced by ruminants-methane (CH4). In this context, this study aims to assess the effect of two biochar sources and inclusion levels on rumen fermentation parameters in vitro. METHODS: Two sources of biochar (agro-forestry residues, AFB, and potato peel, PPB) were added at two levels (5 and 10%, dry matter (DM) basis) to two basal substrates (haylage and corn silage) and incubated 24-h with rumen inocula to assess the effects on CH4 production and main rumen fermentation parameters in vitro. RESULTS: AFB and PPB were obtained at different carbonization conditions resulting in different apparent surface areas, ash content, pH at the point of zero charge (pHpzc), and elemental analysis. Relative to control (0% biochar), biochar supplementation kept unaffected total gas production and yield (mL and mL/g DM, p = 0.140 and p = 0.240, respectively) and fermentation pH (p = 0.666), increased CH4production and yield (mL and mL/g DM, respectively, p = 0.001) and ammonia-N (NH3-N, p = 0.040), and decreased total volatile fatty acids (VFA) production (p < 0.001) and H2 generated and consumed (p ≤ 0.001). Biochar sources and inclusion levels had no negative effect on most of the fermentation parameters and efficiency. Acetic:propionic acid ratio (p = 0.048) and H2 consumed (p = 0.019) were lower with AFB inclusion when compared to PPB. Biochar inclusion at 10% reduced H2 consumed (p < 0.001) and tended to reduce total gas production (p = 0.055). Total VFA production (p = 0.019), acetic acid proportion (p = 0.011) and H2 generated (p = 0.048) were the lowest with AFB supplemented at 10%, no differences being observed among the other treatments. The basal substrate affected most fermentation parameters independently of biochar source and level used. DISCUSSION: Biochar supplementation increased NH3-N content, iso-butyric, iso-valeric and valeric acid proportions, and decreased VFA production suggesting a reduced energy supply for microbial growth, higher proteolysis and deamination of substrate N, and a decrease of NH3-N incorporation into microbial protein. No interaction was found between substrate and biochar source or level on any of the parameters measured. Although AFB and PPB had different textural and compositional characteristics, their effects on the rumen fermentation parameters were similar, the only observed effects being due to AFB included at 10%. Biochar supplementation promoted CH4 production regardless of the source and inclusion level, suggesting that there may be other effects beyond biomass and temperature of production of biochar, highlighting the need to consider other characteristics to better identify the mechanism by which biochar may influence CH4 production.

Ammonia and greenhouse gas emissions following the application of clinoptilolite on the litter of a breeding hen house.

The husbandry of chicken for meat generates high levels of gases, being a serious problem for the health of birds and workers as well as for the environment. The aim of the present study was to assess the effect of clinoptilolite as litter additive on the concentrations and emissions of ammonia (NH3), nitrous oxide (N2O), carbon dioxide (CO2), and methane (CH4) from a breeding hen house under Mediterranean climate conditions. Two similar breeding hen houses were selected, and one house was assigned as control whereas the other house was treated with clinoptilolite as a litter additive. Data were collected during the winter season, in two occasions, first between 26 November and 18 December 2017 and second from 1 to 20 February 2018. Results showed that the application of clinoptilolite on the litter of a breeding hen house reduces the NH3 and N2O losses in 28 and 34%, respectively, but appears to have no effect on CO2 losses. In addition, the in-house CH4 concentrations were below the detection limits.

A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care.

CONTEXT: Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps. OBJECTIVES: To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes. METHODS: A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent. RESULTS: Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature. CONCLUSION: Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.

Dataset on ammonia, nitrous oxide, methane, and carbon dioxide fluxes from two soils fertilized amended with treated and non-treated cattle slurry.

The current data article presents a set of fluxes of ammonia (NH3), nitrous oxide (N2O), methane (CH4), and carbon dioxide (CO2) measured from two different soils under a Mediterranean double-cropping system (oat in autumn/winter followed by maize in spring/summer). The two soils were fertilized using four different treatments: (i) Injection of raw cattle slurry (100 mm depth), (ii) application of raw cattle slurry followed by soil incorporation (20 mm depth), (iii) band application of acidified (pH=5.5) cattle slurry followed by soil incorporation (20 mm depth), and (iv) band application of acidified (pH=5.5) cattle slurry without soil incorporation. A non-amended soil was also considered as control treatment. The data presented here were obtained over a three years experiment between 2012 and 2015. Fluxes were measured in a period between slurry applications to soil (before plant seeding) till crop harvest. The data presented here are supporting the research article "Band application of acidified slurry as an alternative to slurry injection in a Mediterranean double-cropping system: Agronomic effect and gaseous emissions" (Fangueiro et al., 2018).

Cancer Care Professionals' Attitudes Toward Systematic Standardized Symptom Assessment and the Edmonton Symptom Assessment System After Large-Scale Population-Based Implementation in Ontario, Canada.

CONTEXT: Cancer patients experience a high symptom burden throughout their illness. Despite this, patients' symptoms and needs are often not adequately screened for, assessed, and managed. OBJECTIVES: This study investigated the attitudes of cancer care professionals toward standardized systematic symptom assessment and the Edmonton Symptom Assessment System (ESAS) and their self-reported use of the instrument in daily practice in a large healthcare jurisdiction where this is routine. METHODS: A 21-item electronic survey, eliciting both closed and open-ended anonymous responses, was distributed to all 2806 cancer care professionals from four major provider groups: physicians, nurses, radiotherapists, and psychosocial oncology (PSO) staff at the 14 Regional Cancer Centres across Ontario, Canada. RESULTS: A total of 1065 questionnaires were returned (response rate: 38%); 960 were eligible for analysis. Most respondents (88%) considered symptom management to be within their scope of practice. Sixty-six percent of physicians considered the use of standardized tools to screen for symptoms as "best practice," compared to 81% and 93% of nurses and PSO staff, respectively. Sixty-seven percent of physicians and 85% of nurses found the ESAS to be a useful starting point to assess patients' symptoms. Seventy-nine percent of physicians looked at their patient's ESAS scores at visits either "always" or "often," compared to 29%, 66%, and 89% of radiotherapists, PSO staff, and nurses, respectively. Several areas for improvement of ESAS use and symptom screening were identified. CONCLUSION: Findings show significant albeit variable uptake across disciplines in the use of the ESAS since program initiation. Several barriers to using the ESAS in daily practice were identified. These need to be addressed.

Congenital skeletal abnormalities in a tawny owl chick (Strix aluco).

In this case report, we describe a tawny owl chick (Strix aluco) coming from a Wild Fauna Recovery Center with multiple congenital malformations in the limbs. The animal was unable to fly and showed marked malnutrition and poor general appearance. Physical, radiologic, and anatomic examinations showed osseous malformations including dislocation of radius and carpometacarpus with abnormal nonfunctional fixation of ligamentum propatagialis, absence of most parts of the bones of the manus in both wings, and twisted nonfused left tarsometatarsus with marked griphosis of digits. Routine toxicologic and pathologic examinations did not reveal a specific etiology.

The Komesaroff anaesthetic machine for delivering sevoflurane to dogs.

Objective To quantify the vapour output of the Komesaroff machine when using sevoflurane and to determine its performance for inducing and maintaining sevoflurane anaesthesia in dogs. Study design Prospective experimental study. Animals Six clinically normal beagles, aged 3-6 years and weighing 20 ± 1.65 kg (mean ± SEM). Methods The first study was performed using five Komesaroff vaporizers to measure the sevoflurane concentration delivered at each tap setting (I to IV) at 5, 10, 15, 20, 25, 30 and 35 minutes. For this study a ventilator was connected to the Komesaroff machine and set to deliver a tidal volume of 250 mL at 10 cycles minute-1; oxygen flow was 100 mL minute-1. A three-litre reservoir bag was attached to the Y-piece connector to act as a lung model. In the second study anaesthesia was induced in dogs with sevoflurane delivered by face-mask mask and carried in 2 L minute-1 100% oxygen and with the vaporizer set at the fully open position. The quality and speed of induction were recorded. After orotracheal intubation, anaesthesia was maintained for 60 minutes with sevoflurane using an oxygen flow of 100 mL minute-1. The dogs were allowed to breathe spontaneously. The respiratory rate (RR), heart rate (HR), oesophageal temperature, systolic (SAP) mean (MAP) and diastolic (DAP) arterial pressure, end-tidal CO2 concentration (Fe'CO2) end-tidal (Fe'SEVO) and peak-inspired (FiSEVO) percentages of sevoflurane, and vaporizer tap setting were recorded every 5 minutes during anaesthesia. Results The delivery of sevoflurane was constant for each vaporizer setting. The mean output of sevoflurane was 0.44 ± 0.01% for setting I, 2.59 ± 0.18% for setting II, 3.28 ± 0.22% for setting III and 3.1 ± 0.5% for setting IV. In the second study, the mean induction time was 7.72 ± 0.60 minutes and the quality of the induction was good in all dogs. The mean vaporizer tap setting for the maintenance of anaesthesia was 3.48 ± 0.12 and the mean values for Fe'SEVO and FiSEVO were 2.42 ± 0.04% and 2.87 ± 0.06%, respectively. The pedal withdrawal reflex persisted throughout anaesthesia. Conclusions It proved impossible to produce surgical anaesthesia with sevoflurane delivered by the Komesaroff machine despite the highest possible sevoflurane concentration being delivered. Clinical relevance Sevoflurane delivered from the Komesaroff machine cannot be relied upon to maintain surgical anaesthesia in spontaneously breathing dogs.

[Leptin as a marker of sexual dimorphism in newborn infants]. / Leptina como marcadora do dimorfismo sexual em recém-nascidos.

OBJECTIVE: To determine cord blood leptin levels in newborns appropriate for gestational age, according to gender, birth weight, birth height and ponderal index. METHODS: A cross-sectional study was carried out with 132 term newborns appropriate for gestational age (68 females, 64 males), gestational age between 35-42 weeks. Data were collected through interviews with the mothers at the maternity, anthropometrycal study of the newborns, and cord blood estradiol, testosterone and leptin assays obtained immediately after birth. RESULTS: The levels of leptin were significantly higher in females than in males (8.34+/-0.65 ng/ml versus 6.06+/-0.71 ng/ml; p = 0.000). The concentrations of estradiol and testosterone did not differ between males and females. Leptin levels were positively correlated with gestational age (r = 0.394, p < 0.01), birth weight (r = 0.466, p < 0.01), birth length (r = 0.335, p < 0.01) and ponderal index (r = 0.326, p < 0.01). CONCLUSIONS: Leptin concentration in the umbilical cord is positively correlated with gestational age, birth weight, birth height, and ponderal index, suggesting its participation in the neonatal growth process. In addition, a gender difference with higher levels of leptin in females neonates was observed, suggesting that the sexual dimorphism in relation to body composition already exists in newborns.

Clinical practice guidelines for delirium management: potential application in palliative care.

CONTEXT: Delirium occurs in patients across a wide array of health care settings. The extent to which formal management guidelines exist or are adaptable to palliative care is unclear. OBJECTIVES: This review aims to 1) source published delirium management guidelines with potential relevance to palliative care settings, 2) discuss the process of guideline development, 3) appraise their clinical utility, and 4) outline the processes of their implementation and evaluation and make recommendations for future guideline development. METHODS: We searched PubMed (1990-2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with multidisciplinary input from delirium researchers and other relevant stakeholders at an international delirium study planning meeting. RESULTS: There is a paucity of high-level evidence for pharmacological and non-pharmacological interventions in the management of delirium in palliative care. However, multiple delirium guidelines for clinical practice have been developed, with recommendations derived from "expert opinion" for areas where research evidence is lacking. In addition to their potential benefits, limitations of clinical guidelines warrant consideration. Guidelines should be appraised and then adapted for use in a particular setting before implementation. Further research is needed on the evaluation of guidelines, as disseminated and implemented in a clinical setting, focusing on measurable outcomes in addition to their impact on quality of care. CONCLUSION: Delirium clinical guidelines are available but the level of evidence is limited. More robust evidence is required for future guideline development.

Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development.

CONTEXT: Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context. OBJECTIVES: To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development. METHODS: We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium. RESULTS: The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo. CONCLUSION: Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.