Successful Use of Propofol After Failed Palliative Sedation in Patients With Refractory Symptoms.

Context: Propofol is a general anesthetic used in multiple clinical scenarios. Despite growing evidence supporting its use in palliative care, propofol is rarely used in palliative sedation. Reluctance toward the adoption of propofol as a sedative agent is often associated with fear of adverse events such as respiratory arrest. Objectives: We aimed to describe efficacy and safety of palliative sedation in refractory sedation with propofol using a protocol based on low, incremental dosing. Methods: A retrospective observational study featuring inpatients receiving sedative treatment with propofol in our palliative care unit in Madrid (Spain) between March 1, 2018 and February 28, 2023, following a newly developed protocol. Results: During the study period, 22 patients underwent sedation with propofol. Propofol was used successfully to control different refractory symptoms, mainly psychoexistential suffering and delirium. All patients had undergone previous failed attempts at sedation with other medications (midazolam or lemovepromazine) and presented risk factors for complicated sedation. All patients achieved satisfactory (profound) levels of sedation measured with the Ramsay Sedation Scale, but total doses varied greatly between patients. Most patients (17, 77%) received combined therapy with propofol and other sedative medications to harness synergies. The median time between start of sedation with propofol and death was 26.0 hours. No cases of apnea or death during induction were recorded. Conclusion: A protocol for palliative sedation with propofol based on low, incremental dosing, with the option of administering an initial induction bolus, shows excellent results regarding adequate levels of sedation, without observing apnea or respiratory depression. Our results promote the use of propofol to achieve palliative sedation in patients with refractory symptoms and risk factors for complicated sedation at the end of life.

Smoke emissions from biomass burning in Central Mexico and their impact on air quality in Mexico City: May 2019 case study.

Smoke emissions from biomass burning considerably influence regional and local air quality. Many natural wildfires and agricultural burns occur annually in Central Mexico during the hot, dry season (March to May), potentially leading to air quality problems. Nevertheless, the impact of these biomass burning emissions on Mexico City's air quality has not been investigated in depth. This study examines a severely deteriorated air quality case from 11 to 16 May 2019, during which fine particle concentrations (PM2.5) exceeded the 99th percentile of the available official dataset (2005-2019). Specifically, this work aims to highlight the role of fires and regional pollution in the severe episode observed in Mexico City, identifying the fires that were the sources of regional pollution, the type of fuel burned in those fires, and the dominant atmospheric transport pattern. Biomass burning emissions were calculated for different land cover types using satellite data from the Visible Infrared Imaging Radiometer Suite (VIIRS) and the Moderate-Resolution Imaging Spectroradiometer (MODIS). PM2.5 increased by a factor of 2 at some monitoring sites, and ozone concentration increased to 40 % in Mexico City during the poor air quality episode. Our results indicate that over 50 % of the fire activity observed during the 2019 fire season was concentrated in May in Central Mexico. The burning activity was mainly seen over shrubland and forest between 10 and 15 May. Moreover, the fire radiative power analysis indicates that most energy was associated with burning shrubland and forests. Organic carbon emissions were estimated highest on 14 and 15 May, coinciding with the largest number of fires. Back trajectory analysis indicates that enhanced concentration of air pollutants in Mexico City originated from biomass burning detected in neighboring states: Guerrero, Michoacán, and the State of Mexico. Smoke from fires on the specific vegetation cover was advected into Mexico City and contributed to the bad air quality episode. Further meteorological analysis evidenced that the fire intensity and emissions were worsened by low humidity and the late onset of the rainy season in Central Mexico.

A Comprehensive Analysis of Factors Associated with Intimate Partner Femicide: A Systematic Review.

There has been a growing concern about violence against women by intimate partners due to its incidence and severity. This type of violence is a severe problem that has taken the lives of thousands of women worldwide and is expected to continue in the future. A limited amount of research exclusively considers factors related only to these women's deaths. Most focus on deaths of both men and women in an intimate partnership and do not provide precise results on the phenomenon under study. The necessity for an actual synthesis of factors linked solely to women's deaths in heterosexual relationships is key to a comprehensive knowledge of that case. This could assist in identifying high-risk cases by professionals involving an interdisciplinary approach. The study's objective is to systematically review the factors associated with these deaths. Twenty-four studies found inclusion criteria extracted from seven databases (Dialnet, Web of Science, Pubmed, Criminal Justice, Psychology and Behavioral Science Collection, Academic Search Ultimate, and APA Psyarticles). The review was carried out under the PRISMA guidelines' standards. The studies' quality assessment complies with the MMAT guidelines. Findings revealed that there are specific factors of the aggressor, victim, partner's relationship, and environment associated with women's deaths. The results have implications for predicting and preventing women's deaths, providing scientific knowledge applied to develop public action programs, guidelines, and reforms.

The impact of biomass burning emissions on protected natural areas in central and southern Mexico.

Biomass burning from grassland, forests, and agricultural waste results in large amounts of gases and particles emitted to the atmosphere, which affect air quality, population health, crop development, and natural vegetation. Regional atmospheric circulations can transport those plumes of pollutants over hundreds of kilometers, affecting vulnerable environments such as those considered protected natural areas (PNAs). This study evaluates the spatiotemporal distribution of active fires detected, and associated emissions, in central and southern Mexico from satellite data between March and June 2017, to assess the impact of the smoke plumes on protected ecosystems. The arrival of smoke plumes to selected PNAs (both near large urban centers and in remote areas) is assessed using airmass forward trajectories from selected emission sources. The spatial distribution of the remotely derived aerosol optical depth confirms the regional impact of particle emissions from the observed fires on PNAs, particularly in central Mexico. The identified areas of high fire density are also associated with large coarse particle concentrations at the surface. Moreover, there is a significant contribution of organic carbon to the total coarse particle mass, 60% on average. Finally, while most of the impact in ambient pollution is observed in PNAs located close to the regions with active fires in southern Mexico and Central America, the long-range transport of smoke plumes reaching the USA was also confirmed.

Clinical Course of Pediatric Acute Respiratory Distress Syndrome at Moderate Altitude.

Background This is a retrospective case series, and the main objective is to describe the epidemiology, clinical features, and outcomes of pediatric acute respiratory distress syndrome in patients at moderate altitude. Methods Children from the Pediatric Intensive Care Unit (PICU) at the Fundación Cardioinfantil, hospitalized with acute respiratory distress syndrome, were prospectively enrolled from March 2009 to March 2014. We evaluated the demographic data, mechanical ventilation, gas exchange, hemodynamics, and multiorgan dysfunction. Results During the study period, 88 patients met the inclusion criteria. Bronchiolitis and pneumonia were the most common causes of acute respiratory distress syndrome. The overall mortality rate was 19.5%. At the beginning of the study, the average relation between blood pressure and the fraction of inspired oxygen (Pa/Fi) was 130.3 ± 52.2; tidal volume was 7.94 ± 1.7 ml/kg, the plateau pressure 25.3 ± 5.09 cmH2O, and positive end-expiratory pressure was 7.2 ± 3.2 cmH2O. After 24 hours, the mortality rate in the group with severe acute respiratory distress syndrome (Pa/Fi <100) was 46.7%, in the moderate acute respiratory distress syndrome group (Pa/Fi 100-200) it was 11.9%, and finally in the mild acute respiratory distress syndrome group (Pa/Fi 200-300) the mortality was 25%. This study found a relation between serum lactate value and positive end-expiratory pressure and mortality (p = 0.02 and 0.0013). Conclusions This study shows that pediatric acute respiratory distress syndrome patients at moderate altitudes have similar clinical behavior, including mortality rate, to those at low altitudes. However, Pa/Fi is not a good predictor of mortality for patients with mild and moderate acute respiratory distress syndrome.

The Religious Fraternities and Brotherhoods of Seville: Servant Leadership in Social Action.

The religious fraternities and brotherhoods of Seville, Spain, are among the major agents of the social aid carried out in that city. Knowing the characteristics of the servant leadership that have been established by authors such as Greenleaf (1997), we interviewed several representatives of these institutions to determine if they would meet those characteristics and to what extent they configure their teams in charge of carrying out that social aid. Our aim was to verify, through the Rivera and Santos questionnaire (2015), which has been modified to refer to a legal person, if the characteristics that have been assigned to the concept of leader-server and that normally apply to a natural person can also be identified in such corporations. Moreover, we sought to take the opportunity to investigate this structure of work in social action and identify the common characteristics, if any, that make the fraternities and brotherhoods of Seville different from other private agents fighting against poverty.

Tétanos, una enfermedad que se creyó superada: revisión de caso / Tetanus, a disease that was believed to be overcomed: a case review

El tétanos generalizado es una enfermedad infecciosa altamente mortal sin intervenciones médicas y en nuestro tiempo, prevenible mediante inmunización activa. Se presenta el caso de un preescolar de 4 años quien sufre herida cortante en la palma de la mano izquierda y quien se presenta 4 días más tarde con datos clínicos de tétanos generalizado. Fue intubado y admitido a la terapia intensiva del Hospital del Niño Dr. José Renán Esquivel. Su hospitalización se vio caracterizada por neumonía nosocomial, una lesión anfractuosa lingual e inestabilidad autonómica. Además de la antibioticoterapia con metronidazol y la aplicación de inmunoglobulina antitetánica, precisó apoyo hemodinámico con dobutamina y norepinefrina. Para lograr un completo control de las crisis de hipertonía, se ofreció manejo con infusión de midazolam, levetiracetam, clobazam, baclofeno y toxina botulínica.

Generalized tetanus is a highly fatal infectious disease without medical interventions and in our time, preventable by active immunization. The case of a 4-year-old preschooler is presented who suffers a sharp wound in the palm of the left hand and who presents 4 days later with generalized tetanus. He was intubated and admitted to intensive care unit at Dr. José Renán Esquivel Children's Hospital. His hospitalization was characterized by nosocomial pneumonia, an anfractuous lingual lesion and autonomic instability. In addition to antibiotic therapy with metronidazole and the application of tetanus immunoglobulin, hemodynamic support with dobutamine and norepinephrine was required. To achieve complete control of hypertonic crisis, management with infusion of midazolam, levetiracetam, clobazam, baclofen and botulinum toxin was offered.

Sedación paliativa con propofol en una unidad de cuidados paliativos de un hospital de tercer nivel / Palliative sedation in a palliative care unit at a tertiary hospital: is emotional or existential suffering frequent?

ANTECEDENTES Y OBJETIVOS: El aumento de pacientes paliativos genera más situaciones de sedación paliativa complicada. Múltiples factores influyen en la dificultad para realizar una sedación: tolerancia farmacológica, interacciones medicamentosas, afrontamiento emocional... En situaciones de resistencia a fármacos sedantes habituales se precisan otros fármacos como el propofol. El objetivo principal es revisar el uso de propofol en cuidados paliativos y describir varios pacientes que precisaron sedación paliativa con propofol en una Unidad de Cuidados Paliativos (UCP). MATERIAL Y MÉTODO: Estudio descriptivo retrospectivo. Se incluyeron, durante 10 meses, los pacientes que precisaron propofol por una sedación complicada y dos pacientes que fallecieron durante la inducción con propofol. Se registraron múltiples variables y comentarios de las historias clínicas para aclarar el motivo de precisar propofol. RESULTADOS: Existe poca literatura acerca del uso de propofol en cuidados paliativos, basada en casos clínicos aislados o series cortas de pacientes. Cuatro pacientes de nuestra revisión precisaron sedación con propofol. Estos casos fueron significativamente más jóvenes (55,5 años; p = 0,01) y la sedación fue más prolongada (7,5 días; p = 0,05). Los principales motivos para la sedación fueron sintomatología física múltiple o sufrimiento emocional. Todos los pacientes habían precisado dosis altas de otros fármacos sedantes y tuvieron mala respuesta a rescates de otros sedantes en las horas previas. Se propone una guía clínica para el uso de propofol en cuidados paliativos. CONCLUSIONES: - El propofol es un fármaco poco usado en cuidados paliativos, en general con buenos resultados. - Los pacientes que precisaron propofol por una sedación complicada fueron más jóvenes y tuvieron una sedación más prolongada. Destaca el intenso sufrimiento emocional. - Existen factores de sedación complicada o resistencia al midazolam que pueden ayudar a iniciar lo antes posible otro fármaco sedante más eficaz. - Se propone un protocolo para el uso de propofol en paliativos, recomendando comenzar con dosis bajas. - Es necesaria una mayor difusión en el empleo del propofol en una sedación complicada. - Son necesarios estudios que aclaren aspectos dudosos en el uso del propofol

BACKGROUND AND OBJECTIVES: The more patients cared for in palliative care, the more complicated situations arise - for example, palliative sedation due to a refractory symptom. Many factors may complicate a difficult sedation because of drug tolerance or interactions and psychological assessment. Resistance to usual sedative medications is frequent in these situations, and other pharmaceuticals like propofol, with limited use in a palliative care unit (PCU), are needed. The main objectives of this study were to research the available literature, and to report various PCU cases in a tertiary hospital where palliative sedation with propofol was needed. MATERIAL AND METHODS: A descriptive and retrospective study was performed during 10 months. Sedated patients with propofol were included. Also, two patients who died when induction doses of propofol were administered. Many variables were recorded. The clinical records of patients were also reviewed to elucidate the reason why propofol sedation was needed. RESULTS: Few studies exist examining the use of propofol in palliative care based on case reports or small series of cases. Four patients required sedation with propofol. These patients were younger (average age, 55.5, p = 0.01) and had a longer time between sedation onset and death (average time, 7.5 days, p = 0.05). The main symptoms motivating sedation were multifactorial and emotional suffering. All patients receiving propofol needed high-dose maintenance sedation with other sedative medications, and had responded minimally or not at all to rescue doses in previous hours. Updated guidelines for propofol use in PCUs have been drafted, with recommendations and dosages in case of complicated sedation. CONCLUSIONS: - Propofol use is limited in palliative care, usually with good results. Patients where propofol was needed were younger and sedation was longer. There was high emotional suffering in these patients. - There are factors responsible for complicated sedation or limited response to midazolam. Knowledge of these factors might help in providing earlier, more effective sedation. - Guidelines for propofol use in the PCU setting are proposed, recommending low maintenance doses initially. - A more widespread use of propofol as sedative medication in PCUs is recommended when complicated sedation occurs. - Further studies are needed to clarify many aspects of propofol use

[Imported malaria in a general hospital in Madrid]. / Paludismo importado en un hospital general de Madrid.

INTRODUCTION: To study the clinical and epidemiological characteristics of malaria and the diagnosis of this condition in a general hospital that does not have a specialized tropical medicine unit. METHODS: Retrospective study of all malaria cases diagnosed by thick film and/or PCR-positive status for any Plasmodium spp. from 1999 to 2003 in Hospital Príncipe de Asturias in Alcalá de Henares (Madrid, Spain). RESULTS: Over the period studied, 89 cases of malaria were diagnosed. Most patients were African immigrants who had recently left their countries of origin (52%), or immigrants residing in Spain who had traveled to Africa for a short visit (35%) and did not take prophylaxis. The distribution of cases by species was Plasmodium falciparum 89%, P. ovale 7% and P. malariae 4%. Clinical data were non-specific and the percentage of severe complications was low (6.7%). A second-generation test for rapid detection of P. falciparum antigen (PfHRP2) was studied in a group of 46 patients with suspected malaria; the results obtained were similar to thick film as compared to PCR for diagnosing P. falciparum infection. CONCLUSIONS: Access to information on prevention and chemoprophylaxis should be available to all travelers, particularly immigrants visiting their countries of origin. Most semi-immune patients with uncomplicated malaria can be treated on an outpatient basis. PfHRP2 antigen detection, a fast, reliable method for diagnosing malaria due to P. falciparum, can be used in addition to the thick film method in our setting.

Paludismo importado en un hospital general de Madrid / Imported malaria in a general hospital in Madrid

Introducción. Estudiar las características epidemiológicas de la malaria y su diagnóstico en un hospital general sin unidad especializada de Medicina Tropical. Métodos. Se estudiaron retrospectivamente todos los casos de malaria diagnosticados con gota gruesa y/o reacción en cadena de la polimerasa (PCR) positivas para cualquier especie de Plasmodium desde 1999 a 2003 en el Hospital Príncipe de Asturias de Alcalá de Henares (Madrid). Resultados. En este período se diagnosticaron 89 casos de malaria. La mayoría eran inmigrantes africanos recién llegados (52%) o inmigrantes residentes en España que viajaron a África de visita durante poco tiempo (35%) y no tomaron ninguna profilaxis. La distribución por especies fue: Plasmodium falciparum, 89%; P. ovale, 7%; y P. malariae, 4%. La clínica fue inespecífica y el porcentaje de complicaciones graves fue bajo (6,7%). Con los test de detección rápida de antígenos palúdicos PfPRH2 de segunda generación realizados en un grupo de 46 pacientes con sospecha de malaria se obtuvieron resultados equiparables a la gota gruesa en comparación con la PCR en el diagnóstico de la infección por P. falciparum. Conclusiones. Se debe mejorar el acceso a la información preventiva y a la quimioprofilaxis para todos los viajeros, especialmente para los inmigrantes que vuelven de visita a sus países de origen. La mayoría de pacientes semiinmunes con malaria no complicada puede recibir un tratamiento ambulatorio. En nuestro medio, la detección rápida de antígenos puede ser una técnica complementaria de la gota gruesa, sencilla y fiable en el diagnóstico rápido de malaria por P. falciparum (AU)

Introduction. To study the clinical and epidemiological characteristics of malaria and the diagnosis of this condition in a general hospital that does not have a specialized tropical medicine unit. Methods. Retrospective study of all malaria cases diagnosed by thick film and/or PCR-positive status for any Plasmodium spp. from 1999 to 2003 in Hospital Príncipe de Asturias in Alcalá de Henares (Madrid, Spain). Results. Over the period studied, 89 cases of malaria were diagnosed. Most patients were African immigrants who had recently left their countries of origin (52%), or immigrants residing in Spain who had traveled to Africa for a short visit (35%) and did not take prophylaxis. The distribution of cases by species was Plasmodium falciparum 89%, P. ovale 7% and P. malariae 4%. Clinical data were non-specific and the percentage of severe complications was low (6.7%). A second-generation test for rapid detection of P. falciparum antigen (PfHRP2) was studied in a group of 46 patients with suspected malaria; the results obtained were similar to thick film as compared to PCR for diagnosing P. falciparum infection. Conclusions. Access to information on prevention and chemoprophylaxis should be available to all travelers, particularly immigrants visiting their countries of origin. Most semi-immune patients with uncomplicated malaria can be treated on an outpatient basis. PfHRP2 antigen detection, a fast, reliable method for diagnosing malaria due to P. falciparum, can be used in addition to the thick film method in our setting (AU)