Dor e fatores associados em pacientes atendidos em um serviço de urgência odontológica no sul do Brasil / Pain and associated factors in patients attending an emergency dental service in southern Brazil

O objetivo deste estudo transversal foi avaliaro desfecho dor e fatores associados em pacientes atendidos em um serviço de urgência odontológica no sul do Brasil. Foram avaliados 137 prontuários provenientes de um projeto de extensão para capacitação em atendimento odontológico de urgência da Universidade Federal de Santa Maria (Santa Maria/RS), referentes ao período de abril de 2017 a dezembro de 2018. Os dados contidos na ficha clínica, autorrelatados pelos pacientes, foram coletados e variáveis relacionadas às características socioeconômicas, médicas e odontológicas foram submetidas à análise estatística descritiva e regressão de Poisson multivariada. A prevalência de dor nestes pacientes foi de 65,2%e a hipótese diagnósticamais prevalente foi de pulpite aguda irreversível (46,2% dos casos). A procura por atendimento foi maiorna faixa etária entre 40-59 anos (48,6%), no sexo feminino (64%), em pacientes sem nível superior (85,3%) e os dentes mais frequentemente tratados foram os posteriores (82,7%). Houve associação entre a presença de dor e variáveis médicas, sendo queos pacientes com mais de duas doençassistêmicas apresentaram maior prevalência de dor. O preenchimento inadequado dos prontuários odontológicos foi um achado comum, o que pode prejudicar o estabelecimento do perfil epidemiológico destes pacientes e o planejamento dos atendimentos futuros de forma eficiente, além de poder acarretar problemas jurídicos (AU).

This cross-sectional study aimed to evaluate the pain outcome and associated factorsin patients attending an emergency dental service in southern Brazil. One hundred and thirty-seven (137) patient records from an extension project for emergency dental care training at the Universidade Federal de Santa Maria (Santa Maria, RS, Brazil), relative to the period from April 2017 to December 2018, were evaluated. The data in the records, self-reported by the patients, were collected, and variables related to socioeconomic, medical and dental characteristics were subjected to descriptive statistical analysis and multivariate Poisson regression. The prevalence of pain in these patients was 65.2%, and the most prevalent diagnostic hypothesis was irreversible acute pulpitis (46.2% of the cases). The demand for care was greater in the age group between40-59 years (48.6%), in women (64%), in patients without university education (85.3%), and posterior teeth were the most frequently treated (82.7%). There was an association between the presence of pain and medical variables, being that patients with morethan two systemic diseases had a higher prevalence of pain. The inadequate completion of dental records was a common finding, which can impair the establishment of the epidemiological profile of these patients and the efficient planning of future dental care services, as well as cause legal problems (AU).

Direct Cortical Stimulation in Neurosurgical Emergencies: Single-Center Experience in 2 Patients.

BACKGROUND: Intraoperative neuromonitoring (IONM) is widely used for elective resection of eloquently located brain tumors to increase safety and extent of resection. Owing to the need for specially trained personnel for IONM and the sophisticated, time-consuming technical setup, standard IONM is usually not suitable for emergency situations. We report the use of a device that can be operated by the neurosurgeon autonomously for monopolar brain mapping in 2 emergency cases. METHODS: Both patients were initially scheduled for elective neurosurgery under IONM. Acute neurological deterioration in both cases led to emergency surgery. For monopolar cortical/subcortical stimulation, a standard monopolar probe was connected to a new device enabling electromyography real-time tracking of 8 muscles. Preoperative application of subdermal electromyography needles and intraoperative handling of the device were performed by the neurosurgeons independently. RESULTS: Cortical mapping of the motor cortex was performed in both patients with a threshold of 4 mA in case 1 and 14 mA in case 2. Gross total resection with residual tumor volume of <2 mL in case 1 and subtotal resection with residual tumor volume of 4.2 mL in case 2 were achieved under use of the new device without any new neurological deficit. Grade IV glioblastoma was diagnosed in both patients. CONCLUSIONS: We demonstrate the feasibility of monopolar stimulation in 2 patients undergoing emergency neurosurgery using a device autonomously operated by the surgeon. Owing to fast setup and nondemanding handling, monopolar stimulation could be used during emergency neurosurgery to extend resection with preservation of neurological function in both cases.

Urgent-start peritoneal dialysis versus haemodialysis for people with chronic kidney disease.

BACKGROUND: Patients with chronic kidney disease (CKD) who require urgent initiation of dialysis but without having a permanent dialysis access have traditionally commenced haemodialysis (HD) using a central venous catheter (CVC). However, several studies have reported that urgent initiation of peritoneal dialysis (PD) is a viable alternative option for such patients. OBJECTIVES: This review aimed to examine the benefits and harms of urgent-start PD compared to HD initiated using a CVC in adults and children with CKD requiring long-term kidney replacement therapy. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 for randomised controlled trials through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 11 February 2020) and EMBASE (OVID) (1980 to 11 February 2020) were searched. SELECTION CRITERIA: All randomised controlled trials (RCTs), quasi-RCTs and non-RCTs comparing urgent-start PD to HD initiated using a CVC. DATA COLLECTION AND ANALYSIS: Two authors extracted data and assessed the quality of studies independently. Additional information was obtained from the primary investigators. The estimates of effect were analysed using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI). The GRADE framework was used to make judgments regarding certainty of the evidence for each outcome. MAIN RESULTS: Overall, seven observational studies (991 participants) were included: three prospective cohort studies and four retrospective cohort studies. All the outcomes except one (bacteraemia) were graded as very low certainty of evidence given that all included studies were observational studies and few events resulting in imprecision, and inconsistent findings. Urgent-start PD may reduce the incidence of catheter-related bacteraemia compared with HD initiated with a CVC (2 studies, 301 participants: RR 0.13, 95% CI 0.04 to 0.41; I2 = 0%; low certainty evidence), which translated into 131 fewer bacteraemia episodes per 1000 (95% CI 89 to 145 fewer). Urgent-start PD has uncertain effects on peritonitis risk (2 studies, 301 participants: RR 1.78, 95% CI 0.23 to 13.62; I2 = 0%; very low certainty evidence), exit-site/tunnel infection (1 study, 419 participants: RR 3.99, 95% CI 1.2 to 12.05; very low certainty evidence), exit-site bleeding (1 study, 178 participants: RR 0.12, 95% CI 0.01 to 2.33; very low certainty evidence), catheter malfunction (2 studies; 597 participants: RR 0.26, 95% CI: 0.07 to 0.91; I2 = 66%; very low certainty evidence), catheter re-adjustment (2 studies, 225 participants: RR: 0.13; 95% CI 0.00 to 18.61; I2 = 92%; very low certainty evidence), technique survival (1 study, 123 participants: RR: 1.18, 95% CI 0.87 to 1.61; very low certainty evidence), or patient survival (5 studies, 820 participants; RR 0.68, 95% CI 0.44 to 1.07; I2 = 0%; very low certainty evidence) compared with HD initiated using a CVC. Two studies using different methods of measurements for hospitalisation reported that hospitalisation was similar although one study reported higher hospitalisation rates in HD initiated using a catheter compared with urgent-start PD. AUTHORS' CONCLUSIONS: Compared with HD initiated using a CVC, urgent-start PD may reduce the risk of bacteraemia and had uncertain effects on other complications of dialysis and technique and patient survival. In summary, there are very few studies directly comparing the outcomes of urgent-start PD and HD initiated using a CVC for patients with CKD who need to commence dialysis urgently. This evidence gap needs to be addressed in future studies.

Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms.

Thoracic aortic diseases, including disease of the descending thoracic aorta (DTA), are significant causes of death in the United States. Open repair of the DTA is a physiologically impactful operation with relatively high rates of mortality, paraplegia, and renal failure. Thoracic endovascular aortic repair (TEVAR) has revolutionized treatment of the DTA and has largely supplanted open repair because of lower morbidity and mortality. These Society for Vascular Surgery Practice Guidelines are applicable to the use of TEVAR for descending thoracic aortic aneurysm (TAA) as well as for other rarer pathologic processes of the DTA. Management of aortic dissections and traumatic injuries will be discussed in separate Society for Vascular Surgery documents. In general, there is a lack of high-quality evidence across all TAA diseases, highlighting the need for better comparative effectiveness research. Yet, large single-center experiences, administrative databases, and meta-analyses have consistently reported beneficial effects of TEVAR over open repair, especially in the setting of rupture. Many of the strongest recommendations from this guideline focus on imaging before, during, or after TEVAR and include the following: In patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging, usually computed tomography angiography (CTA) because of its speed and ease of use for preoperative planning. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). If TEVAR is being considered, we recommend fine-cut (≤0.25 mm) CTA of the entire aorta as well as of the iliac and femoral arteries. CTA of the head and neck is also needed to determine the anatomy of the vertebral arteries. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). We recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). We recommend contrast-enhanced computed tomography scanning at 1 month and 12 months after TEVAR and then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is detected at 1 month. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). Finally, based on our review, in patients who could undergo either technique (within the criteria of the device's instructions for use), we recommend TEVAR as the preferred approach to treat elective DTA aneurysms, given its reduced morbidity and length of stay as well as short-term mortality. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). Given the benefits of TEVAR, treatment using a minimally invasive approach is largely based on anatomic eligibility rather than on patient-specific factors, as is the case in open TAA repair. Thus, for isolated lesions of the DTA, TEVAR should be the primary method of repair in both the elective and emergent setting based on improved short-term and midterm mortality as well as decreased morbidity.

Medical emergency kits in ambulatory care clinics.

Implementation and staff perceptions of usability and feasibility.

Design and study of nitric oxide portable producing device using continuous discharging arc plasma reaction keeping low energy efficiency for viral pneumonia emergency therapy.

This study investigated the efficiency of a portable nitric oxide (NO) inhalation device through optimizing its design and structure. The portable rescue device could be used in clinical applications in outbreaks of viral pneumonia such as SARS. To reduce energy consumption for battery-powered portable usage, NO micro-channel plasma reactions induced by a continuous discharge arc were employed. A single-use airway tube could be combined with an intubation tube in clinical applications. In the experiment, a switching transistor controlled high frequency DC (12.5 kHz) was used to create a continuous discharge arc between two stainless steel electrodes (1-mm separation) after high-voltage breakthrough. A rotate instrument was employed to change the direction angle between the airflow and discharge arc, tube filled with Calcium hydroxide connected with gas outlet for reducing NO2, gas flow rate and input voltage were evaluated separately with concentration of NO and NO2/NO ratio. Results showed that a 2 L/min air flow direction from the cathode to the anode of electrodes (direction angle was zero) under 4 V input voltages produced 32.5±3.8 ppm NO, and the NO2/NO ratio reduced to less than 10%, stable output of nitric oxide might be convenient and effective for NO inhalation therapy. Modularization of the design produced a portable NO inhalation device that has potential for use in clinical applications as it is low cost, easy to disinfect, consumes low levels of energy and is ready to use.

Stop the Bleed: The Impact of a Basic Bleeding Control Course on High School Personnel's Perceptions of Self-Efficacy and School Preparedness.

Background: Uncontrolled bleeding is the leading cause of preventable death from trauma. The Stop the Bleed (STB) initiative provides basic education about bleeding to potential immediate responders. The present study aimed to assess the perceptions of self-efficacy and school preparedness related to responding to a life-threatening bleeding emergency in school personnel at an urban high school. Methods: High school personnel from an urban high school (N = 156) completed a 1-hour STB course that included a didactic and hands-on component. Participants rated their agreement with statements about self-efficacy and school preparedness on a 5-point Likert-type scale, responded to items regarding how school personnel could be better prepared for life-threatening emergencies, and had the option to provide written responses pre- and post-course. Findings: Independent samples t tests revealed that perceptions of self-efficacy and school preparedness increased after the course (p < .001). Before the course, 87% of participants felt they needed training, 80% felt the school needed clearer procedures, and 74% felt the school required more equipment for a life-threatening bleeding incident compared with 63%, 69%, and 78% post-course, respectively. Thematic analysis of written responses revealed that participants desired higher frequencies of STB training, more equipment, clearer school procedures, and realistic training scenarios with students. Conclusions/Application to Practice: The STB course increased both perceptions of self-efficacy and school preparedness in a sample of high school personnel. Qualitative analyses provided insight to personnel's opinion of STB's effectiveness and what is necessary to maintain or follow through with this knowledge after completion of the course.

Rescue oxygenation success by cannula or scalpel-bougie emergency front-of-neck access in an anaesthetised porcine model.

In the obese, the evidence for the choice of the optimal emergency front-of-neck access technique is very limited and conflicting. We compared cannula and scalpel-bougie emergency front-of-neck access techniques in an anaesthetised porcine model with thick pretracheal tissue. Cannula and scalpel-bougie cricothyroidotomy techniques were performed in 11 and 12 anaesthetised pigs, respectively. Following successful tracheal access, oxygenation was commenced and continued for 5 min using Rapid-O2 device for cannula and circle breathing system for scalpel-bougie study groups. The primary outcome was a successful rescue oxygenation determined by maintenance of arterial oxygen saturation >90% 5 min after the beginning of oxygenation. Secondary outcomes included success rate of airway device placement, time to successful airway device placement, and trauma to the neck and airway. The success rate of rescue oxygenation was 18% after cannula, and 83% after scalpel-bougie technique (P = 0.003). The success rate of airway device placement was 73% with cannula and 92% with scalpel-bougie technique (P = 0.317). Median (inter-quartile-range) times to successful airway device placement were 108 (30-256) and 90 (63-188) seconds (P = 0.762) for cannula and scalpel-bougie emergency front-of-neck access, respectively. Proportion of animals with iatrogenic trauma additional to the procedure itself was 27% for cannula and 75% for scalpel-bougie technique (P = 0.039). Thus, in the porcine model of obesity, the scalpel-bougie technique was more successful in establishing and maintaining rescue oxygenation than cannula-based technique; however, it was associated with a higher risk of severe trauma.

Autoinjector device for rapid administration of drugs and antidotes in emergency situations and in mass casualty management.

There are several situations such as medical emergencies and incidents involving mass casualties where drugs and antidotes have to be administered immediately along with other first aid at the site of the event. Self-administration by the affected person or by a companion is required as a life-saving measure. Autoinjector devices (AIDs) are useful for the rapid administration of drugs and antidotes and they can also be used by those who have not been medically trained. This makes them very convenient for emergency and mass casualty management. An AID has a drug cartridge with an embedded needle for subcutaneous or intramuscular injection, which is usually painless. The drugs are delivered slowly by the AID across a large area in the muscle, which increases the absorption and the drug effects are equal to that of intravenous administration. A variety of AIDs are available, such as atropine and pralidoxime for nerve agent poisoning, epinephrine for anaphylactic shock and allergy, diazepam for seizures, sumatriptan for migraine, amikacin for antibacterial treatment, buprenorphine for pain relief and monoclonal antibodies for a variety of diseases. This review describes the published peer-reviewed literature identified by online searches of journal databases.

Resources Recommended for the Care of Pediatric Patients in Hospitals.

It is crucial that all children are provided with high-quality and safe health care. Pediatric inpatient needs are unique in regard to policies, equipment, facilities, and personnel. The intent of this clinical report is to provide recommendations for the resources necessary to provide high-quality and safe pediatric inpatient medical care.

Lymphocyte-to-monocyte ratio effectively predicts survival outcome of patients with obstructive colorectal cancer.

BACKGROUND: Obstructive colorectal cancer (OCC) is always accompanied by severe complications, and the optimal strategy for patients with OCC remains undetermined. Different from emergency surgery (ES), self-expandable metal stents (SEMS) as a bridge to surgery (BTS), could increase the likelihood of primary anastomosis. However, the stent failure and related complications might give rise to a high recurrence rate. Few studies have focused on the indications for either method, and the relationship between preoperative inflammation indexes and the prognosis of OCC is still underestimated. AIM: To explore the indications for ES and BTS in OCCs based on preoperative inflammation indexes. METHODS: One hundred and twenty-eight patients who underwent ES or BTS from 2008 to 2015 were enrolled. Receiver operating characteristic (ROC) curve analysis was used to define the optimal preoperative inflammation index and its cutoff point. Kaplan-Meier analyses and Cox proportional hazards models were applied to assess the association between the preoperative inflammation indexes and the survival outcomes [overall survival (OS) and disease-free survival (DFS)]. Stratification analysis was performed to identify the subgroups that would benefit from ES or BTS. RESULTS: OS and DFS were comparable between the ES and BTS groups (P > 0.05). ROC curve analysis showed derived neutrophil-to-lymphocyte ratio (dNLR) as the optimal biomarker for the prediction of DFS in ES (P < 0.05). Lymphocyte-to-monocyte ratio (LMR) was recommended for BTS with regard to OS and DFS (P < 0.05). dNLR was related to stoma construction (P = 0.001), pneumonia (P = 0.054), and DFS (P = 0.009) in ES. LMR was closely related to lymph node invasion (LVI) (P = 0.009), OS (P = 0.020), and DFS (P = 0.046) in the BTS group. dNLR was an independent risk factor for ES in both OS (P = 0.032) and DFS (P = 0.016). LMR affected OS (P = 0.053) and DFS (P = 0.052) in the BTS group. LMR could differentiate the OS between the ES and BTS groups (P < 0.05). CONCLUSION: Preoperative dNLR and LMR could predict OS and DFS in patients undergoing ES and BTS, respectively. For OCC, as the potential benefit group, patients with a low LMR might be preferred for BTS via SEMS insertion.

Successful ROTEM-guided transfusion therapy in a case of rural paediatric trauma.

Massive transfusion therapy in severe paediatric trauma is a challenge. When this occurs in a rural setting, the potential delays in accessing medical services can lead to worse coagulopathy on presentation. We report successful treatment of a child post-traumatic lower limb amputation where treatment was only initiated 3 hours postinjury due to difficulties in access/retrieval. Rotational thromboelastometry (ROTEM)-guided, goal-directed haemostatic therapy perioperatively utilising a blood product ratio of 2:2:1 units of red blood cell:free frozen plasma:platelet reverted his coagulopathy. This report aims to raise awareness of the utility of ROTEM in paediatric trauma.

Effectiveness of the American College of Surgeons Bleeding Control Basic Training Among Laypeople Applying Different Tourniquet Types: A Randomized Clinical Trial.

Importance: More than 500 000 laypeople in the United States have been trained in hemorrhage control, including tourniquet application, under the Stop the Bleed campaign. However, it is unclear whether after hemorrhage control training participants become proficient in a specific type of tourniquet or can also use other tourniquets effectively. Objective: To assess whether participants completing the American College of Surgeons Bleeding Control Basic (B-Con) training with Combat Application Tourniquets (CATs) can effectively apply bleeding control principles using other tourniquet types (commercial and improvised). Design, Setting, and Participants: This nonblinded, crossover, sequential randomized clinical trial with internal control assessed a volunteer sample of laypeople who attended a B-Con course at Gillette Stadium and the Longwood Medical Area in Boston, Massachusetts, for correct application of each of 5 different tourniquet types immediately after B-Con training from April 4, 2018, to October 9, 2018. The order of application varied for each participant using randomly generated permutated blocks. Interventions: Full B-Con course, including cognitive and skill sessions, that taught bleeding care, wound pressure and packing, and CAT application. Main Outcomes and Measures: Correct tourniquet application (applied pressure of ≥250 mm Hg with a 2-minute time cap) in a simulated scenario for 3 commercial tourniquets (Special Operation Forces Tactical Tourniquet, Stretch-Wrap-and-Tuck Tourniquet, and Rapid Application Tourniquet System) and improvised tourniquet compared with correct CAT application as an internal control using 4 pairwise Bonferroni-corrected comparisons with the McNemar test. Results: A total of 102 participants (50 [49.0%] male; median [interquartile range] age, 37.5 [27.0-53.0] years) were included in the study. Participants correctly applied the CAT at a significantly higher rate (92.2%) than all other commercial tourniquet types (Special Operation Forces Tactical Tourniquet, 68.6%; Stretch-Wrap-and-Tuck Tourniquet, 11.8%; Rapid Application Tourniquet System, 11.8%) and the improvised tourniquet (32.4%) (P < .001 for each pairwise comparison). When comparing tourniquets applied correctly, all tourniquet types had higher estimated blood loss, had longer application time, and applied less pressure than the CAT. Conclusions and Relevance: The B-Con principles for correct CAT application are not fully translatable to other commercial or improvised tourniquet types. This study demonstrates a disconnect between the B-Con course and tourniquet designs available for bystander first aid, potentially stemming from the lack of consensus guidelines. These results suggest that current B-Con trainees may not be prepared to care for bleeding patients as tourniquet design evolves. Trial Registration: ClinicalTrials.gov identifier: NCT03538379.