Heterogeneity among countries in the subspecialty of cardiovascular anesthesia in latin america: survey results

OBJECTIVES: To evaluate demographics, workload, training, facilities, and equipment in cardiovascular anesthesia (CVA) in Latin America (LA). DESIGN: A descriptive cross-sectional study with data collected through a survey. SETTING: A multicenter, international web-based questionnaire that included 37 multiple-choice questions. PARTICIPANTS: Physicians and specialists in anesthesiology who regularly participated in cardiovascular surgeries and were members of the scientific societies of the Latin American Confederation of Anesthesiology. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: A total of 484 completed questionnaires were collected. A total of 97.8% of the respondents had a university degree in anesthesiology. Most did not receive formal training in CVA, and only 41.5% received formal training. Moreover, most of them were trained in their own country, and a smaller percentage were trained abroad. Half of the respondents reported receiving <12 months of training. A third part of the respondents had received training in transesophageal echocardiography. Only 5.8% of the respondents worked exclusively in CVA, and a high percentage dedicated <60% of their weekly work hours to this subspecialty. A total of 80.6% of the centers had <3 cardiac surgery operating rooms. Only one-third of the centers performed heart/lung transplantation, venoarterial extracorporeal membrane oxygenation, venovenous extracorporeal membrane oxygenation, and ventricular assist device implantation. CONCLUSIONS: A significant lack of training programs in anesthesiology practice and complex procedures in medical centers in LA are evident. Thus, basic accredited programs should be developed in medical centers in LA.

Heterogeneity Among Countries in the Subspecialty of Cardiovascular Anesthesia in Latin America: Survey Results.

OBJECTIVES: To evaluate demographics, workload, training, facilities, and equipment in cardiovascular anesthesia (CVA) in Latin America (LA). DESIGN: A descriptive cross-sectional study with data collected through a survey. SETTING: A multicenter, international web-based questionnaire that included 37 multiple-choice questions. PARTICIPANTS: Physicians and specialists in anesthesiology who regularly participated in cardiovascular surgeries and were members of the scientific societies of the Latin American Confederation of Anesthesiology. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: A total of 484 completed questionnaires were collected. A total of 97.8% of the respondents had a university degree in anesthesiology. Most did not receive formal training in CVA, and only 41.5% received formal training. Moreover, most of them were trained in their own country, and a smaller percentage were trained abroad. Half of the respondents reported receiving <12 months of training. A third part of the respondents had received training in transesophageal echocardiography. Only 5.8% of the respondents worked exclusively in CVA, and a high percentage dedicated <60% of their weekly work hours to this subspecialty. A total of 80.6% of the centers had <3 cardiac surgery operating rooms. Only one-third of the centers performed heart/lung transplantation, venoarterial extracorporeal membrane oxygenation, venovenous extracorporeal membrane oxygenation, and ventricular assist device implantation. CONCLUSIONS: A significant lack of training programs in anesthesiology practice and complex procedures in medical centers in LA are evident. Thus, basic accredited programs should be developed in medical centers in LA.

Role of Pv-aCO2 gradient and Pv-aCO2/Ca-vO2 ratio during cardiac surgery: a retrospective observational study.

INTRODUCTION: Arterial lactate, mixed venous O2 saturation, venous minus arterial CO2 partial pressure (Pv-aCO2) and the ratio between this gradient and the arterial minus venous oxygen content (Pv-aCO2/Ca-vO2) were proposed as markers of tissue hypoperfusion and oxygenation. The main goals were to characterize the determinants of Pv-aCO2 and Pv-aCO2/Ca-vO2, and the interchangeability of the variables calculated from mixed and central venous samples. METHODS: 35 cardiac surgery patients were included. Variables were measured or calculated: after anesthesia induction (T1), end of surgery (T2), and at 6...8.ßhours intervals after ICU admission (T3 and T4). RESULTS: Macrohemodynamics was characterized by increased cardiac index and low systemic vascular resistances after surgery (p.ß<.ß0.05). Hemoglobin, arterial-pH, lactate, and systemic O2 metabolism showed significant changes during the study (p.ß<.ß0.05). Pv-aCO2 remained high and without changes, Pv-aCO2/Ca-vO2 was also high and decreased at T4 (p.ß<.ß0.05). A significant correlation was observed globally and at each time interval, between Pv-aCO2 or Pv-aCO2/Ca-vO2 with factors that may affect the CO2 hemoglobin dissociation. A multilevel linear regression model with Pv-aCO2 and Pv-aCO2/Ca-vO2 as outcome variables showed a significant association for Pv-aCO2 with SvO2, and BE (p.ß<.ß0.05), while Pv-aCO2/Ca-vO2 was significantly associated with Hb, SvO2, and BE (p.ß<.ß0.05) but not with cardiac output. Measurements and calculations from mixed and central venous blood were not interchangeable. CONCLUSIONS: Pv-aCO2 and Pv-aCO2/Ca-vO2 could be influenced by different factors that affect the CO2 dissociation curve, these variables should be considered with caution in cardiac surgery patients. Finally, central venous and mixed values were not interchangeable.

Role of Pv-aCO2 gradient and Pv-aCO2/Ca-vO2 ratio during cardiac surgery: a retrospective observational study

Abstract Introduction: Arterial lactate, mixed venous O2 saturation, venous minus arterial CO2 partial pressure (Pv-aCO2) and the ratio between this gradient and the arterial minus venous oxygen content (Pv-aCO2/Ca-vO2) were proposed as markers of tissue hypoperfusion and oxygenation. The main goals were to characterize the determinants of Pv-aCO2 and Pv-aCO2/Ca-vO2, and the interchangeability of the variables calculated from mixed and central venous samples. Methods: 35 cardiac surgery patients were included. Variables were measured or calculated: after anesthesia induction (T1), end of surgery (T2), and at 6-8 hours intervals after ICU admission (T3 and T4). Results: Macrohemodynamics was characterized by increased cardiac index and low systemic vascular resistances after surgery (p < 0.05). Hemoglobin, arterial-pH, lactate, and systemic O2 metabolism showed significant changes during the study (p < 0.05). Pv-aCO2 remained high and without changes, Pv-aCO2/Ca-vO2 was also high and decreased at T4 (p < 0.05). A significant correlation was observed globally and at each time interval, between Pv-aCO2 or Pv-aCO2/Ca-vO2 with factors that may affect the CO2 hemoglobin dissociation. A multilevel linear regression model with Pv-aCO2 and Pv-aCO2/Ca-vO2 as outcome variables showed a significant association for Pv-aCO2 with SvO2, and BE (p < 0.05), while Pv-aCO2/Ca-vO2 was significantly associated with Hb, SvO2, and BE (p < 0.05) but not with cardiac output. Measurements and calculations from mixed and central venous blood were not interchangeable. Conclusions: Pv-aCO2 and Pv-aCO2/Ca-vO2 could be influenced by different factors that affect the CO2 dissociation curve, these variables should be considered with caution in cardiac surgery patients. Finally, central venous and mixed values were not interchangeable.

Prevalencia de fragilidad en cirugía electiva para personas mayores usuarios del Hospital de Clínicas. Análisis de la población quirúrgica de personas mayores del Hospital de Clínicas "Dr. Manuel Quintela" (marzo 2019-marzo 2020) / Prevalence of frailty in elective surgery for older adults at Clínicas Hospital. Analysis of the surgical population of older adults at "Dr. Manuel Quintela" University Hospital from March, 2029 to March, 2020 / Prevalência de fragilidade em cirurgia eletiva em idosos usuários do Hospital de Clínicas. Análise da população cirúrgica de idosos do Hospital de Clínicas "Dr. Manuel Quintela" (março 2019-março 2020)

La fragilidad determina una incapacidad para enfrentar estresores debido a la disminución de las reservas fisiológicas multisistémicas. El acto anestésico quirúrgico constituye un evento estresante y la presencia de fragilidad es un factor de riesgo independiente de morbimortalidad perioperatoria. Identificarla permitiría abordar los factores reversibles que la determinan con la intención de disminuir los riesgos inherentes a dicho acto. Su detección en la valoración perioperatoria aporta información relevante que no se obtiene con una evaluación tradicional. Este enfoque se ha convertido en un estándar en la valoración perioperatoria de personas mayores. El objetivo del estudio es valorar la prevalencia de fragilidad en la cirugía electiva de personas mayores en el Hospital de Clínicas. Es un estudio prospectivo y descriptivo. Fue aprobado por el Comité de Ética institucional. Se reclutaron 206 pacientes de 65 años y más, coordinados para cirugía electiva, entre marzo del 2019 y marzo del 2020. Se aplicó la Escala de Fragilidad de Edmonton Reportada (REFS) para la detección de la fragilidad. La prevalencia de fragilidad fue del 22,8% con un IC 16-29,6, por lo que decimos que es alta en esta población y similar al de otros contextos quirúrgicos y no quirúrgicos. Se encontraron un número significativamente mayor de hipertensión arterial, arritmias, diabetes, hipotiroidismo y tabaquismo entre los pacientes frágiles. Su prevalencia e impacto en la morbimortalidad operatoria constituyen razones de peso para su inclusión en la valoración perioperatoria en nuestro sistema de salud así como la capacitación de los anestesiólogos en la detección de la fragilidad a través del uso de herramientas prácticas, válidas y confiables.

Frailty determines an inability to cope with stressors due to decreased multisystem physiologic reserves. The surgical anesthetic act is a stressful event and the presence of frailty is an independent risk factor for perioperative morbidity and mortality Detection of frailty would allow for addressing reversible factors causing it, with the intention of reducing the risks that are inherent to anesthetic acts. Detection in the perioperative assessment provides relevant information that is not obtained in a traditional evaluation. This approach has become the standard in perioperative assessment of geriatric surgical patients. The study aims to assess the prevalence of frailty in elective surgery for the elderly at Clínicas Hospital. Method: prospective, descriptive study approved by the institutional Ethics Committee. 206 patients aged 65 years old and over who had been coordinated for elective surgery were recruited for the study between March, 2019 and March, 2020. The Reported Edmonton Frailty Scale (REFS) was applied to detect frailty. Prevalence of frailty was 22.8% with a CI of 16-29 in this population, rather high and similar to the frail patients percentages in other surgical and non-surgical settings. Significantly higher numbers of arterial hypertension, arrhythmias, diabetes and hypothyroidism cases and tobacco users were found among frail patients. Prevalence and impact of frailty on operative morbidity and mortality are compelling reasons for its inclusion in the perioperative assessment of our health system, as well as the training of anesthesiologists in the detection of frailty through the use of practical, valid and reliable tools.

A fragilidade determina uma incapacidade de lidar com estressores devido à diminuição das reservas fisiológicas multissistêmicas. O ato anestésico cirúrgico é um evento estressante e a presença de fragilidade é um fator de risco independente para morbimortalidade perioperatória. Identificá-lo permitiria abordar os fatores reversíveis que o determinam com o intuito de reduzir os riscos inerentes ao referido ato. Sua detecção na avaliação perioperatória fornece informações relevantes que não são obtidas com uma avaliação tradicional. Essa abordagem tornou-se padrão na avaliação perioperatória de idosos. O objetivo do estudo é avaliar a prevalência de fragilidade em cirurgias eletivas para idosos no Hospital de Clínicas. Realizou-se um estudo prospectivo e descritivo, aprovado pelo Comitê de Ética institucional. 206 pacientes com 65 anos ou mais, coordenados para cirurgia eletiva, foram recrutados entre março de 2019 e março de 2020. A Reported Edmonton Frailty Scale (REFS) foi aplicada para detectar fragilidade. A prevalência de fragilidade foi de 22,8% com um IC de 16-29,6, pelo que podemos dizer que é elevada nesta população e semelhante à de outros contextos cirúrgicos e não cirúrgicos. Números significativamente maiores de hipertensão arterial, arritmias, diabetes, hipotireoidismo e tabagismo foram encontrados entre os pacientes frágeis. A prevalência e impacto da fragilidade na morbimortalidade operatória são razões convincentes para sua inclusão na avaliação perioperatória em nosso sistema de saúde, bem como para o treinamento de anestesistas na detecção de fragilidade por meio do uso de ferramentas práticas, válidas e confiáveis.

Joint Recommendations From The Latin American Association of Cardiac and Endovascular Surgery (LACES) and The Cardiovascular Anesthesia Committee of The Latin American Confederation of Anesthesia Societies (CLASA) on the Timing for Cardiac Surgery After COVID-19 Infection

ABSTRACT Introduction: Since the coronavirus disease 2019 (COVID-19) pandemic, cardiac surgeries in patients with previous infection by COVID-19 were suspended or postponed, which led to surgeries performed in patients with an advanced stage of their disease and an increase in the waiting list. There is a heterogeneous attitude in Latin America on the optimal timing to cardiac surgery in patients with previous COVID-19 infection due to scarce data on its outcome. Two Latin American associations joined to establish common suggestions on the optimal timing of surgery in patients with previous COVID-19 infection. Methods: Data collection was performed using a pre-established form, which included year of publication, objective, type of study (prospective/retrospective, descriptive/analytical), number of patients, year of study, waiting time between infection and surgery, type of surgery, morbidity, mortality, and conclusions regarding the association between mortality and morbidity. Final recommendations were approved by the board of directors of Latin American Association of Cardiac and Endovascular Surgery (LACES) and Latin American Confederation of Anesthesia Societies (CLASA). Results: Of the initial 1,016 articles, 11 comprised the final selection. Only six of them included patients who underwent cardiac surgery. According to the analyzed literature, optimal timing for cardiac surgery needs to consider the following aspects: deferable surgery, symptomatic COVID-19 infection, completeness of COVID-19 vaccination. Conclusion: These recommendations derive from the analysis of the scarce literature published at present on outcomes after cardiac surgery in patients with previous COVID-19 infection. These are to be taken as a dynamic recommendation in which Latin American reality was taken into consideration.

Joint Recommendations From The Latin American Association of Cardiac and Endovascular Surgery (LACES) and The Cardiovascular Anesthesia Committee of The Latin American Confederation of Anesthesia Societies (CLASA) on the Timing for Cardiac Surgery After COVID-19 Infection.

INTRODUCTION: Since the coronavirus disease 2019 (COVID-19) pandemic, cardiac surgeries in patients with previous infection by COVID-19 were suspended or postponed, which led to surgeries performed in patients with an advanced stage of their disease and an increase in the waiting list. There is a heterogeneous attitude in Latin America on the optimal timing to cardiac surgery in patients with previous COVID-19 infection due to scarce data on its outcome. Two Latin American associations joined to establish common suggestions on the optimal timing of surgery in patients with previous COVID-19 infection. METHODS: Data collection was performed using a pre-established form, which included year of publication, objective, type of study (prospective/retrospective, descriptive/analytical), number of patients, year of study, waiting time between infection and surgery, type of surgery, morbidity, mortality, and conclusions regarding the association between mortality and morbidity. Final recommendations were approved by the board of directors of Latin American Association of Cardiac and Endovascular Surgery (LACES) and Latin American Confederation of Anesthesia Societies (CLASA). RESULTS: Of the initial 1,016 articles, 11 comprised the final selection. Only six of them included patients who underwent cardiac surgery. According to the analyzed literature, optimal timing for cardiac surgery needs to consider the following aspects: deferable surgery, symptomatic COVID-19 infection, completeness of COVID-19 vaccination. CONCLUSION: These recommendations derive from the analysis of the scarce literature published at present on outcomes after cardiac surgery in patients with previous COVID-19 infection. These are to be taken as a dynamic recommendation in which Latin American reality was taken into consideration.

Latin American surgical outcomes study: study protocol for a multicentre international observational cohort study of patient outcomes after surgery in Latin American countries.

Background: Reported data suggest that 4.2 million deaths will occur within 30 days of surgery worldwide each year, half of which are in low- and middle-income countries. Postoperative complications are a leading cause of long-term morbidity and mortality. Patients who survive and leave the hospital after surgical complications regularly experience reductions in long-term survival and functional independence, resulting in increased costs. With a high volume of surgery performed, there is a growing perception of the substantial impact of even minor enhancements in perioperative care. The Latin American Surgical Outcomes Study (LASOS) is an international, multicentre, prospective cohort study of adults submitted to in-patient surgery in Latin America aiming to provide detailed data describing postoperative complications and surgical mortality. Methods: LASOS is a 7 day cohort study of adults undergoing surgery in Latin America. Details of preoperative risk factors, intraoperative care, and postoperative outcomes will be collected. The primary outcome will be in-hospital postoperative complications of any cause. Secondary outcomes include in-hospital all-cause mortality, duration of hospital stay after surgery, and admission to a critical care unit within 30 days after surgery during the index hospitalisation. Results: The LASOS results will be published in peer-reviewed journals, reported and presented at international meetings, and widely disseminated to patients and public in participating countries via mainstream and social media. Conclusions: The LASOS may augment our understanding of postoperative complications and surgial mortality in Latin America. Clinical trial registration: NCT05169164.

A 10 años de la emergencia sanitaria anestésico-quirúrgica en Uruguay. Comparación de los resultados de la oferta actual con la proyectada en 2011 / 10 years after the anesthetic-surgical health emergency in Uruguay. Comparison of the results of the current offer with that projected in 2011 / 10 anos após a emergência de saúde anestésico-cirúrgica no Uruguai. Comparação dos resultados da oferta atual com a projetada para 2011

Resumen: Introducción: durante el 2011 se propuso un modelo de simulación para valorar la oferta, la relación demanda/necesidades y las tendencias en el tiempo de anestesiólogos y establecer escenarios posibles. Objetivo: comparar la oferta actual de anestesiólogos con la proyectada por el modelo de simulación en el año 2011. Material y métodos: se realizó una actualización a partir de las bases de datos disponibles. Se registró número de anestesiólogos titulados y no titulados, su distribución demográfica y se comparó con los escenarios propuestos en un estudio anterior. Resultados: la tasa de médicos con competencias en anestesiología fue de 14,2/100.000 habitantes y la de anestesiólogos titulados 12/100.000. La distribución de edad presentó una mediana de 54 años, el 90% central se encontraba entre 36 y 75 años. El 57% correspondió a mujeres. 21,8 anestesistas/100.000 habitantes corresponden a Montevideo y área metropolitana contra 7/100.000 en el resto del país. Hubo un incremento promedio del 50% en el número de plazas para la formación, un aumento de solicitudes de reválida (11 en el período estudiado) y un incremento del 17,5% de la producción quirúrgica en el subsector público. Conclusiones: el número de anestesiólogos disponibles en el año 2020 sugirió que la proyección realizada en dos de los escenarios propuestos en investigación anterior reprodujeron adecuadamente la oferta real. Se observó un crecimiento de la participación de mujeres, mayor porcentaje en franjas etarias menores, centralización de los recursos humanos en Montevideo y una edad de retiro mayor. La principal limitación sigue siendo contar con información oportuna y de calidad. Es fundamental la utilización de metodologías rigurosas y de aplicaión sistemática para que quienes planifican puedan tomar decisiones informadas.

Summary: Introduction: during 2011 a simulation method was proposed to assess the needs and trends over time of anesthesiologists and establish possible scenarios. Objective: compare the current situation with the projections formulated in 2011 by the simulation method to evaluate anesthesiologists' supply and demand. Material and methods: an update of the available databases was revised. The number and demographic distribution of the anesthesiologist workforce were recorded and compared with the proposed scenarios. Results: the number of physicians with anesthesiology skills was 14.2/100.000, and wholly trained anesthesiologists were 12/100.000. The age distribution presented a median of 54 years, the central 90% were between 36 and 75 years old. 57% of the anesthesiologist are females. 21.8 workforce in anesthesiology/100.000 corresponds to Montevideo and the metropolitan area, against 7/100.000 in the rest of the country. There was an average increase of 50% in the number of positions for training, an increase in revalidation applications, and a rise of 17.5% in a surgical procedure in the public subsector. Conclusions: the prediction of the number of anesthesiologists and their characteristics for 2020 coincided with two of the proposed scenarios. We verify a growth in female participation, a higher percentage in younger age groups, centralization of human resources in Montevideo and higher retirement age. The main limitation was access to reliable information.

Resumo: Introdução: durante 2011, foi proposto um modelo de simulação para avaliar a oferta, demanda / necessidades, tendências ao longo do tempo dos anestesiologistas e estabelecer possíveis cenários. Objetivo: comparar a oferta atual de anestesiologistas com a projetada pelo modelo de simulação em 2011. Material e métodos: foi feita uma atualização das bases de dados disponíveis. O número de anestesiologistas licenciados e não certificados e sua distribuição demográfica foram registrados e comparados com os cenários propostos em um estudo anterior. Resultados: a taxa de médicos com habilidades em anestesiologia foi de 14,2/100.000 habitantes e a de anestesiologistas licenciados de 12/100.000. A distribuição de idade apresentou mediana de 54 anos, os centrais 90% estavam entre 36 e 75 anos. 57% correspondiam a mulheres. 21,8 anestesistas / 100.000 habitantes correspondem a Montevidéu e região metropolitana contra 7 / 100.000 no resto do país. Houve um aumento médio de 50% no número de vagas para treinamentos, um aumento nas solicitações de revalidação (11 no período estudado) e um aumento de 17,5% na produção cirúrgica no subsetor público. Conclusões: o número de anestesiologistas disponíveis em 2020 sugeria que a projeção feita em dos cenários propostos em pesquisas anteriores reproduzia adequadamente a oferta real. Houve crescimento da participação feminina, maior percentual nas faixas etárias mais jovens, centralização dos recursos humanos em Montevidéu e maior idade de aposentadoria. A principal limitação continua sendo a disponibilidade de informaçao oportuna e de qualidade. O uso de metodologias rigorosas e sistematicamente aplicadas é essencial para que aqueles que planejam possam tomar decisões informadas.

A comprehensive spatial-temporal analysis of driving factors of human-caused wildfires in Spain using Geographically Weighted Logistic Regression.

Over the last decades, authorities responsible on forest fire have encouraged research on fire triggering factors, recognizing this as a critical point to achieve a greater understanding of fire occurrence patterns and improve preventive measures. The key objectives of this study are to investigate and analyze spatial-temporal changes in the contribution of wildfire drivers in Spain, and provide deeper insights into the influence of fire features: cause, season and size. We explored several subsets of fire occurrence combining cause (negligence/accident and arson), season (summer-spring and winter-fall) and size (<1 Ha, 1-100 Ha and >100 Ha). The analysis is carried out fitting Geographically Weighted Logistic Regression models in two separate time periods (1988-1992, soon after Spain joined the European Union; and 2006-2010, after several decades of forest management). Our results suggest that human factors are losing performance with climate factors taking over, which may be ultimately related to the success in recent prevention policies. In addition, we found strong differences in the performance of occurrence models across subsets, thus models based on long-term historical fire records might led to misleading conclusions. Overall, fire management should move towards differential prevention measurements and recommendations due to the observed variability in drivers' behavior over time and space, paying special attention to winter fires.

Encapsulation of Ionic Liquids with an Aprotic Heterocyclic Anion (AHA-IL) for CO2 Capture: Preserving the Favorable Thermodynamics and Enhancing the Kinetics of Absorption.

The performance of an ionic liquid with an aprotic heterocyclic anion (AHA-IL), trihexyl(tetradecyl)phosphonium 2-cyanopyrrolide ([P66614][2-CNPyr]), for CO2 capture has been evaluated considering both the thermodynamics and the kinetics of the phenomena. Absorption gravimetric measurements of the gas-liquid equilibrium isotherms of CO2-AHA-IL systems were carried out from 298 to 333 K and at pressures up to 15 bar, analyzing the role of both chemical and physical absorption phenomena in the overall CO2 solubility in the AHA-IL, as has been done previously. In addition, the kinetics of the CO2 chemical absorption process was evaluated by in situ Fourier transform infrared spectroscopy-attenuated total reflection, following the characteristic vibrational signals of the reactants and products over the reaction time. A chemical absorption model was used to describe the time-dependent concentration of species involved in the reactive absorption, obtaining kinetic parameters (such as chemical reaction kinetic constants and diffusion coefficients) as a function of temperatures and pressures. As expected, the results demonstrate that the CO2 absorption rate is mass-transfer-controlled because of the relatively high viscosity of AHA-IL. The AHA-IL was encapsulated in a porous carbon sphere (Encapsulated Ionic Liquid, ENIL) to improve the kinetic performance of the AHA-IL for CO2 capture. The newly synthesized AHA-ENIL material was evaluated as a CO2 sorbent with gravimetric absorption measurements. AHA-ENIL systems preserve the good CO2 absorption capacity of the AHA-IL but drastically enhance the CO2 absorption rate because of the increased gas-liquid surface contact area achieved by solvent encapsulation.

Pulmonary hypertension attenuates the dynamic preload indicators increase during experimental hypovolemia.

BACKGROUND: Pulse pressure (PPV) and stroke volume (SVV) variations may not be reliable in the setting of pulmonary hypertension and/or right ventricular (RV) failure. We hypothesized that RV afterload increase attenuates SVV and PPV during hypovolemia in a rabbit model of pulmonary embolism (PE) secondary to RV dysfunction. METHODS: Seven anesthetized and mechanically ventilated rabbits were studied during four experimental conditions: normovolemia, blood withdrawal, pulmonary embolism and fluid loading of a colloidal solution. Central venous, RV and left ventricular (LV) pressures, and infra-diaphragmatic aortic blood flow (AoF) and pressure were measured. SV was estimated by the integral of systolic AoF. We analyzed RV and LV function through stroke work output curves. PPV and SVV were obtained by the variation of beat-to-beat PP and SV, respectively. We assessed RV and LV diastolic and systolic function by the time rate of relaxation (tau) and the ratio of the first derivative of ventricular pressure and the highest isovolumic developed pressure (dP/dt/DP), respectively. The vasomotor tone was estimated by the dynamic arterial elastance (Eadyn = PPV/SVV). RESULTS: PPV and SVV increased significantly during hemorrhage and returned to baseline values after PE which was associated to biventricular right-downward of the stroke work curves and a decrease of AoF and SV (P < 0.05). RV systo-diastolic function and LV systolic function were impaired. All the animals were nonresponders after volume expansion. Eadyn did not show any significant change during the different experimental conditions. CONCLUSIONS: The dynamic preload indicators (SVV and PPV) were significantly reduced after a normotensive PE in hypovolemic animals, mainly by the systo-diastolic dysfunction of the RV associated with LV systolic impairment, which makes the animals nonresponsive to volume loading. This normalization of dynamic preload indices may prevent the detrimental consequence of fluid loading.

Conjunctival tumors in children: histopathologic diagnosis in 165 cases.

PURPOSE: Conjunctival tissue tumors have a varied presentation, and few series studies on pediatric patients have been published. The objective of this paper is to report the histopathologic diagnoses (spanning over 1988-2013) of conjunctival tumors in children younger than 14 years. METHODS: We conducted a retrospective, descriptive, and observational study by reviewing the database of all children in whom a conjunctival tumor was surgically removed at Hospital de Ojos y Oídos "Dr. Rodolfo Robles V.," Benemérito Comité Pro Ciegos y Sordos de Guatemala. The data pertaining to gender, age, and histopathologic diagnosis of all cases was collected. The same ocular pathologist made all diagnoses. RESULTS: One hundred sixty-five cases were found, with a mean age of 7.88 years, being 91 (55.15%) male subjects. Melanocytic lesions were the most common tumors found (30.91% of cases), with only one case (0.60%) being malignant. CONCLUSIONS: Melanocytic lesions were the most common tumors found, and of all the cases, only one was malignant; this was in a patient with xeroderma pigmentosum. These findings are consistent with those reported in other studies regarding the frequencies of the histopathology of conjunctival tumors in the pediatric population.

Conjunctival tumors in children: histopathologic diagnosis in 165 cases / Tumores conjuntival em crianças: diagnóstico histopatológico em 165 casos

ABSTRACT Purpose: Conjunctival tissue tumors have a varied presentation, and few series studies on pediatric patients have been published. The objective of this paper is to report the histopathologic diagnoses (spanning over 1988-2013) of conjunctival tumors in children younger than 14 years. Methods: We conducted a retrospective, descriptive, and observational study by reviewing the database of all children in whom a conjunctival tumor was surgically removed at Hospital de Ojos y Oídos "Dr. Rodolfo Robles V.," Benemérito Comité Pro Ciegos y Sordos de Guatemala. The data pertaining to gender, age, and histopathologic diagnosis of all cases was collected. The same ocular pathologist made all diagnoses. Results: One hundred sixty-five cases were found, with a mean age of 7.88 years, being 91 (55.15%) male subjects. Melanocytic lesions were the most common tumors found (30.91% of cases), with only one case (0.60%) being malignant. Conclusions: Melanocytic lesions were the most common tumors found, and of all the cases, only one was malignant; this was in a patient with xeroderma pigmentosum. These findings are consistent with those reported in other studies regarding the frequencies of the histopathology of conjunctival tumors in the pediatric population.

RESUMO Objetivo: Tumores do tecido conjuntival tem uma apresentação variada. Poucas séries de pacientes pediátricos foram publicadas. O objetivo deste trabalho é apresentar os diagnósticos histopatológicos de tumores conjuntivais em crianças com menos de 14 anos de idade, obtidas durante um período de 25 anos. Métodos: Estudo retrospectivo, descritivo e observacional foi realizado. Nós revisamos o banco de dados de todas as crianças em quem um tumor conjuntival foi removido cirurgicamente no Hospital de Ojos y oidos "Dr. Rodolfo Robles V.," Benemérito Comité Pro Ciegos y Sordos de Guatemala. Sexo, idade e diagnóstico histopatológico de todos os casos foram compilados. O mesmo patologista ocular fez todos os diagnósticos. Resultados: Cento e sessenta e cinco casos foram encontrados, com média de 7,88 anos, sendo 91 (55,15%) do sexo masculino. Lesões melanocíticas foram as mais frequentes (30,91% dos casos). Apenas um caso (0,60%) era maligno. Conclusões: Lesões melanocíticas foram as mais frequentes. Do total, apenas uma lesão era maligna, o que correspondeu a um paciente com xeroderma pigmentoso. Estes resultados são consistentes com o relatado em outros estudos quanto à frequência de diagnóstico histopatológico de tumores da conjuntiva na população pediátrica.

Effects of early hemodynamic resuscitation on left ventricular performance and microcirculatory function during endotoxic shock.

BACKGROUND: Microcirculation and macrohemodynamics are severely compromised during septic shock. However, the relationship between these two compartments needs to be further investigated. We hypothesized that early resuscitation restores left ventricular (LV) performance and microcirculatory function but fails to prevent metabolic disorders. We studied the effects of an early resuscitation protocol (ERP) on LV pressure/volume loops-derived parameters, sublingual microcirculation, and metabolic alterations during endotoxic shock. METHODS: Twenty-five pigs were randomized into three groups: LPS group: Escherichia coli lipopolysaccharide (LPS); ERP group: LPS + ERP based on volume expansion, dobutamine, and noradrenaline infusion; Sham group. LV pressure/volume-derived parameters, systemic hemodynamics, sublingual microcirculation, and metabolic profile were assessed at baseline and after completing the resuscitation protocol. RESULTS: LPS significantly decreased LV end-diastolic volume, myocardial contractility, stroke work, and cardiac index (CI). Early resuscitation preserved preload, and myocardial contractility, increased CI and heart rate (p < .05). LPS severely diminished sublingual microvascular flow index (MFI), perfused vascular density (PVD), and the proportion of perfused vessels (PPV), while increased the heterogeneity flow index (HFI) (p < .05). Despite MFI was relatively preserved, MVD, PVD, and HFI were significantly impaired after resuscitation (p < .05). The macro- and microcirculatory changes were associated with increased lactic acidosis and mixed venous O2 saturation when compared to baseline values (p < .05). The scatter plot between mean arterial pressure (MAP) and MFI showed a biphasic relationship, suggesting that the values were within the limits of microvascular autoregulation when MAP was above 71 ± 6 mm Hg (R (2) = 0.63). CONCLUSIONS: Early hemodynamic resuscitation was effective to restore macrohemodynamia and myocardial contractility. Despite MAP and MFI were relatively preserved, the persistent microvascular dysfunction could explain metabolic disorders. The relationship between micro- and systemic hemodynamia and their impact on cellular function and metabolism needs to be further studied during endotoxic shock.

The increase of vasomotor tone avoids the ability of the dynamic preload indicators to estimate fluid responsiveness.

BACKGROUND: The use of vasoconstrictor can affect the dynamic indices to predict fluid responsiveness. We investigate the effects of an increase of vascular tone on dynamic variables of fluid responsiveness in a rabbit model of hemorrhage, and to examine the ability of the arterial pressure surrogates dynamic indices to track systolic volume variation (SVV) during hypovolemia under increased vasomotor tone. METHODS: Eighteen anesthetized and mechanically ventilated rabbits were studied during normovolemia (BL) and after blood progressive removal (15 mL/kg, BW). Other two sets of data were obtained during PHE infusion with normovolemia (BL + PHE) and during hypovolemia (BW + PHE). We measured central venous and left ventricular (LV) pressures and infra diaphragmatic aortic blood flow (AoF) and pressure. Pulse pressure variation (PPV), systolic pressure variation (SPV) and SVV were estimated manually by the variation of beat-to-beat PP, SP and SV, respectively. We also calculated PPVapnea as 100 × (PPmax-PPmin)/PP during apnea. The vasomotor tone was estimated by total peripheral resistance (TPR = mean aortic pressure/mean AoF), dynamic arterial elastance (Eadyn = PPV/SVV) and arterial compliance (C = SV/PP). We assessed LV preload by LV end-diastolic pressure (LVEDP). We compared the trending abilities between SVV and pressure surrogate indices using four-quadrant plots and polar plots. RESULTS: Baseline PPV, SPV, PPVapnea, and SVV increased significantly during hemorrhage, with a decrease of AoF (P < 0.05). PHE induced significant TPR and Eadyn increase and C decrease in bled animals, and a further decrease in AoF with a significant decrease of all dynamic indices. There was a significant correlation between SVV and PPV, PPVapnea and SPV in normal vasomotor tone (r2 ≥ 0.5). The concordance rate was 91%, 95% and 76% between SVV and PPV, PPVapnea and SPV, respectively, in accordance with the polar plot analysis. During PHE infusion, there was no correlation between SVV and its surrogates, and both four-quadrant plot and polar plot showed poor trending. CONCLUSION: In this animal model of hemorrhage and increased vasomotor tone induced by phenylephrine the ability of dynamic indices to predict fluid responsiveness seems to be impaired, masking the true fluid loss. Moreover, the arterial pressure surrogates have not the reliable trending ability against SVV.

Utilidad de un método estadístico desimulación para evaluar la oferta y demanda de anestesiólogos en Uruguay (2011-2025): propuesta para prospección y planificación de necesidadde recursos humanos en Anestesiología / Usefulness of statistical simulation to assess supply and demand for anesthesiologists in Uruguay (2011-2025): a proposal for research and planning the need for human resources in Anesthesiology

Introducción: existe una crisis de recursos humanos en Anestesiología que afecta fundamentalmente al subsectorpúblico. Objetivos: el propósito del presente estudio fue estimar el déficit o superávit actual de anestesistas tomando como año base el 2011 y analizarlo en base a técnicas de simulación estadística hasta el 2025.Material y método: se caracterizó la oferta/demanda de anestesiólogos creando diferentes escenarios de acuerdo a los datos obtenidos por el Ministerio de Salud Pública en el año 2010 y por el Censo Nacional del 2011. Esta información se integró generando un modelo de simulación mediante lametodología de dinámica de sistemas. Esta permite realizar análisis de sensibilidad: incorporar diferentes escenarios y ver cómo impacta en la evolución del modelo año a año.Resultados: para un escenario de 11,28 anestesiólogos por cada 100.000 habitantes, el déficit se cerraría en el 2015. Manteniendo el número de residentes en 80, al finalizar el período se alcanzaría un excedente de 50 (12,7/100.000). Esto contemplaría las proyecciones del aumento de cirugías. Para una demanda mayor y superior a la media de los países desarrollados (15 cada 100.000) sería necesario incrementar la formación a 113 residentes. Una de las principales limitaciones en la aplicación del modelo fue la falta de organización apropiada del trabajo anestesiológico.Conclusión: el modelo permitió establecer proyecciones de las necesidades de recursos humanos año a año; estas estimaciones pueden adaptarse frente a situaciones cambiantes y de esta forma elaborar un plan de formación de recursos humanos en anestesia acorde a estos.

Introduction: there is a human resource shortage in Anesthesiology that mainly affects the public sub-sector.Objectives: the study aimed at estimating the current deficit or surplus of anesthesiologists. It considered 2011 as a baseline and used statistical simulation to analyse the situation until 2025.Method: the supply/demand of anesthesiologist was categorized by creating different scenarios according to the data collected from the Ministry of Public Health in 2010 and the National Census of 2011. This information was integrated and a simulation model wascreated by the system dynamics method. This method allows for the analysis of sensitivity: to incorporate different scenarios and study their impact on the modelÆs evolution every year.Results: deficit would disappear in a scenario with 11.28 anesthesiologists every 100,000 inhabitants. If the number of residents remains stable in 80, there would be a 50 surplus towards the end of the period (12.7 /100,000). These figures contemplate projectionsfor the increase of surgeries. In the event of a demand that is larger and greater than the average in developedcountries (15 every 100,000) it would be necessary to train as many as 113 residents. One of the main limitations for the application of the model was the absence of an appropriate organization of the practice of anesthesiology.Conclusion: the model enabled to project the need of human resources for every year. These estimates may be adapted to changing situations and thus, allows for the design of a plan to train human resources in anesthesiology to meet needs.

Introdução: existe uma crise de recursos humanos em Anestesiologia que afeta fundamentalmente o subsetorpúblico.Objetivos: o propósito deste estudo é estimar o déficit ou superávit atual de anestesistas através de uma análise que utiliza técnicas de simulação estatística para fazer uma projeção até o ano 2025 considerando 2011 como ano base.Material e método: a oferta/demanda de anestesistas foi simulada criando diferentes situações de acordo com os dados obtidos pelo Ministério de Saúde Pública em 2010 e pelo Censo Nacional de 2011. Esta informação foi integrada gerando um modelo de simulação queutiliza dinâmica de sistemas. Dessa forma se pode fazer uma análise de sensibilidade: incorporar diferentes situações e conhecer seu impacto na evolução do modelo a cada ano.Resultados: considerando uma situação com 11,28 anestesistas por cada 100.000 habitantes, o déficit terminaria em 2015. Mantendo o número de residentes em 80, um excedente de 50 (12,7/100.000) seria alcançado nofim do período, considerando as projeções de aumento de cirurgias. Para uma demanda maior e superior à média dos países desenvolvidos (15 cada 100.000) seria necessário aumentar a formação a 113 residentes. Uma dasprincipais limitações da aplicação do modelo é a falta de uma organização apropriada do trabalho em anestesiologia.Conclusão: o modelo permitiu estabelecer projeções das necessidades de recursos humanos ano a ano; estas estimativas podem ser adaptadas para diferentes situações e dessa maneira elaborar um plano de formação de recursos humanos em anestesia de acordo com essas previsões.

Modelling the ecological vulnerability to forest fires in mediterranean ecosystems using geographic information technologies.

Forest fires represent a major driver of change at the ecosystem and landscape levels in the Mediterranean region. Environmental features and vegetation are key factors to estimate the ecological vulnerability to fire; defined as the degree to which an ecosystem is susceptible to, and unable to cope with, adverse effects of fire (provided a fire occurs). Given the predicted climatic changes for the region, it is urgent to validate spatially explicit tools for assessing this vulnerability in order to support the design of new fire prevention and restoration strategies. This work presents an innovative GIS-based modelling approach to evaluate the ecological vulnerability to fire of an ecosystem, considering its main components (soil and vegetation) and different time scales. The evaluation was structured in three stages: short-term (focussed on soil degradation risk), medium-term (focussed on changes in vegetation), and coupling of the short- and medium-term vulnerabilities. The model was implemented in two regions: Aragón (inland North-eastern Spain) and Valencia (eastern Spain). Maps of the ecological vulnerability to fire were produced at a regional scale. We partially validated the model in a study site combining two complementary approaches that focused on testing the adequacy of model's predictions in three ecosystems, all very common in fire-prone landscapes of eastern Spain: two shrublands and a pine forest. Both approaches were based on the comparison of model's predictions with values of NDVI (Normalized Difference Vegetation Index), which is considered a good proxy for green biomass. Both methods showed that the model's performance is satisfactory when applied to the three selected vegetation types.

Embarazo y transposición de grandes vasos congénitamente corregida / Pregnancy and congenitally corrected transposition of the great vessels

Los casos de pacientes embarazadas con cardiopatías congénitas complejas han incrementado su incidencia en los últimos años dados los avances terapéuticos actuales. Presentamosel caso clínico de una paciente que tiene como antecedente personal una transposición de grandes vasos arteriales congénitamente corregida y que cursa su primer embarazo, se discute sobre su desenlace, y, a propósito del mismo, los efectos de las cardiopatías en el estado grávido puerperal y viceversa, y de la importancia del asesoramiento y abordaje multidisciplinario de dichas pacientes.

Given current therapeutic progress made in the recent years, the cases of pregnant women with congenitalheart disease have increased in terms of incidence. The study presents the clinical case of a patient who has apersonal history of congenitally corrected transposition of the great arteries and is pregnant with her first child. Her outcome is discussed, and based on this, the effects of heart disease in the pregnancy-puerperal cycle and viceversa are likewise discussed, the same as the importanceof counseling and the multidisciplinary approach of these patients.

Graças aos avanços terapêuticos atuais o número de gestantes com cardiopatias congênitas complexas vem aumentando. Apresentamos o caso clínico de uma paciente que tem como antecedente pessoal uma transposição de grandes vasos arteriais corrigida congenitamentee que está grávida pela primeira vez. A evolução da gestação e sua terminação, os efeitos das cardiopatias sobre o estado grávido puerperal e vice versa, a importância do assessoramento e a importância da abordagem multiprofissional dessas pacientes sãodiscutidos.