A randomised double blind clinical trial to compare surgical field bleeding during endoscopic sinus surgery with clonidine-based or remifentanil-based hypotensive anaesthesia.

BACKGROUND: Significant bleeding during functional endoscopic naso-sinusal surgery (FESS) impairs recognition of anatomical references and may negatively affect surgical outcome. Anaesthesia including clonidine as an adjuntive hypotensive agent may reduce intraoperative bleeding. METHODS: A randomised comparison of clonidine-based vs remifentanil-based hypotensive anaesthetic regimen was conducted in patients undergoing FESS. The main assessment was the proportion of subjects with Boezaart scores of surgical field bleeding, as blindly assessed from video recordings by a third surgeon not involved in patient care. RESULTS: A total of 47 subjects underwent FESS and were randomised to clonidine or remifentanil. A significantly lower proportion of patients in the clonidine arm had blindly-assessed Boezaart scores higher than 2, with significantly lower mean blind Boezaart scores at 60 minutes and at 120 minutes. Similar findings were reported by the operating surgeon, and when Wormald and VAS scores were used. Objective estimates of bleeding and the duration of surgery and anaesthesia did not differ between groups. CONCLUSION: The use of clonidine- based controlled hypotensive anaesthesia achieves lower surgical field bleeding during FESS.

Another way of thinking about ADHD: the predictive role of early attachment deprivation in adolescents' level of symptoms.

PURPOSE: Attention deficit and hyperactivity disorder (ADHD) is one of the most frequent disorders in childhood and adolescence. Both neurocognitive and environmental factors have been related to ADHD. The current study contributes to the documentation of the predictive relation between early attachment deprivation and ADHD. METHOD: Data were collected from 641 adopted adolescents (53.2% girls) aged 11-16 years in five countries, using the DSM oriented scale for ADHD of the Child Behavior Checklist (CBCL) (Achenbach and Rescorla, Manual for the ASEBA school-age forms and profiles. University of Vermont, Research Center for Children, Youth and Families, Burlington, 2001). The influence of attachment deprivation on ADHD symptoms was initially tested taking into consideration several key variables that have been reported as influencing ADHD at the adoptee level (age, gender, length of time in the adoptive family, parents' educational level and marital status), and at the level of the country of origin and country of adoption (poverty, quality of health services and values). The analyses were computed using the multilevel modeling technique. RESULTS: The results showed that an increase in the level of ADHD symptoms was predicted by the duration of exposure to early attachment deprivation, estimated from the age of adoption, after controlling for the influence of adoptee and country variables. The effect of the age of adoption was also demonstrated to be specific to the level of ADHD symptoms in comparison to both the externalizing and internalizing behavior scales of the CBCL. CONCLUSION: Deprivation of stable and sensitive care in infancy may have long-lasting consequences for children's development.

Hypotensive anaesthesia and bleeding during endoscopic sinus surgery: an observational study.

Significant bleeding during functional endoscopic naso-sinusal surgery (FESS) impairs recognition of anatomical references and may negatively affect surgical outcome. Through their hypotensive effect, adjuvant anaesthetic agents may influence intraoperative bleeding. The present study compared intraoperative bleeding in patients undergoing FESS administered a clonidine-based anaesthetic regimen and in patients receiving other an anaesthetic combination with higher acquisition costs. Prospective observational study included 37 subjects undergoing FESS in 2011. Assessment of intraoperative bleeding was according to type of anaesthesia (clonidine vs. opioid derivatives). Patients receiving clonidine (N = 11; 29.7%) presented significantly lower surgical field bleeding scores than those receiving opioid derivatives (N = 26; 70.3%) [mean (SD) Boezaart scores 1.91 (0.53) vs. 2.92 (0.79), p < 0.0001]. The multivariate analysis including baseline characteristics and risk factors related to bleeding intensity showed that the type of drug used for controlled hypotensive anaesthesia was the best predictor of bleeding during FESS, with an OR of 0.03 for clonidine based vs. opioid based anaesthesia (p = 0.014). The anaesthetic combination including clonidine for controlled hypotensive anaesthesia produces lower levels of surgical field bleeding during FESS. Compared with other hypotensive anaesthetics, clonidine is inexpensive and associated with better surgical conditions during FESS. If confirmed through randomized clinical trials, the use of clonidine during FESS can reduce surgical time and improve surgical results through a less bloody field, resulting in lower patient morbidity and improvement of operating room resources.

Assessment of the perception of healthcare barriers and the impact of intravitreal injections on neovascular age-related macular degeneration.

AIM: To evaluate the perception of barriers in healthcare and the impact of intravitreal injections in patients with neovascular age-related macular degeneration (nAMD). METHODS: Cross-sectional study including 108 patients with nAMD in treatment with intravitreal injections. The patients answered a questionnaire with 26 questions (score from 1 to 5) divided in three sections: 1) the disease and its treatment with injections, 2) healthcare barriers and 3) new technologies. RESULTS: The mean age was 80.4 ±â€¯7.0 years and visual acuity (VA) was 75.2 ±â€¯12.4 letters. The main barriers in healthcare were long waiting times (72%), followed by other comorbidities (10%). Some 63% of patients have to wait between 3 and 5 h to attend their clinical visit. Significant anxiety due to the injections (2.8 ±â€¯1.3) was observed, being present in 71% of the cases the day before. A great fear of blindness and losing independence was observed (4.4 ±â€¯0.9 and 4.3 ±â€¯1.1), with no differences in relation to VA, age or sex (p ≥ 0.135). Moreover, 28% of the patients reported that it was quite or very difficult for them to attend the clinical visit, with 69% of the total showing great interest in having a diagnostic device at home. CONCLUSION: The nAMD and its treatment represent a significant burden on patients, among whom there is a great fear of blindness and of losing their independence, the main barrier being the long waiting time for the clinical visit.

Water stable isotopes reveal a complex rainfall to groundwater connectivity in central Honduras.

The inter-mountainous region of central Honduras has been experiencing abrupt urban drinking water shortages during the last decade. Land use fragmentation and rainfall deficits have rapidly reduced surface water quality and quantity in this region. Here we present a 3-yr (2018-2020) tracer study within the headwaters of the Choluteca River basin (2949 km2). We sampled rainfall (weekly N = 156; daily N = 270), drilled wells (N = 166; up to ~300 m depth), boreholes (N = 70; ~4-12 m depth), and springs (N = 128) to assess the spatiotemporal connectivity between rainfall and mean groundwater recharge elevations (MREs). Clear W-shaped incursions characterized rainfall isotopic seasonality from the dry to the wet season. Air mass back trajectory analysis revealed three primary moisture sources: 73 % (east, Caribbean Sea), 17 % (southwest, Pacific Ocean), and 10 % (north; Gulf of Mexico). Groundwater sources exhibited a strong meteoric origin with evidence of secondary evaporation evolution, characterized by low d-excess values. MREs for the drilled wells ranged from 821 to 2018 m asl with a mean value of 1570 ± 150 m asl. Seasonal isotopic variability during dry-wet transitions and the influence of rapid infiltration limited the performance of the MRE method in springs and boreholes. MREs coincided primarily with coniferous forests, pasture, and crop areas, within regions of moderate to high transmissivity. These results are intended to guide the mapping and delineation of critical recharge areas in central Honduras to enhance municipal water regulations, effective environmental protection, and long-term conservation practices.

Minimal model analysis in nondiabetic renal transplant recipients with hepatitis C.

INTRODUCTION: Epidemiological data suggest that hepatitis C virus (HCV) infection may contribute to the development of posttransplantation diabetes mellitus (PTDM). METHODS: We investigated the glucose metabolism in 19 renal transplant recipients with antiHCV antibodies and without DM according to World Health Organization criteria before or after transplantation. We measured insulin sensitivity (SI), glucose effectiveness (SG), and pancreatic insulin response using the frequently sampled intravenous glucose tolerance test (FSIGTT). SI and SG were estimated using the Bergman minimal model method and pancreatic insulin response was expressed as the area under insulin curve (AUIC) between 0 and 19 minutes. RESULTS: Impaired glucose tolerance was shown in 42% of patients, some (31.5%) in the range of glucose intolerance (KG: 1-1.5) and others (10.5%) in the diabetes range (KG < 1). SI and SG were decreased in 39% and 63% of patients, respectively. Pancreatic insulin response revealed high variation among patients although showing a tendency to be enhanced. CONCLUSIONS: A high number of HCV-positive renal transplant recipients without clinically manifest PTDM have impaired glucose tolerance, which suggests the future development of diabetes in these patients.

[Association between diabetes mellitus and hepatitis C in kidney transplant patients]. / Asociación entre diabetes mellitus y hepatitis C en trasplante renal.

BACKGROUND: Diabetes mellitus appearing after transplant (PTDM) has generally been attributed to immunosuppressive treatment. However, the findings of several studies suggest a possible relationship between hepatitis C virus (HCV) infection and diabetes mellitus, both in the general population and in liver or kidney transplant patients. METHODS: We reviewed data corresponding to 325 kidney transplant patients who did not have diabetes before transplant and were treated with ciclosporin A posttransplant. We explored whether factors such as age, gender, weight, renal disease, immunosuppression, rejection episodes or HCV could be independent risk factors for PTDM. RESULTS: Ninety four of the 325 patients were HCV positive and 231 were HCV negative. PTDM was observed in 22.3% of the HCV positive patients versus 6.5% of the HCV negative patients (p < 0.001). The independent factors found by multivariate analysis to be predictive of PTDM were: HCV positivity (OR: 5.65, IC 95%: 2.6-12), body mass index (OR: 1,10, IC 95%: 1.02-1.2) and age (OR: 1.07, IC 95%: 1.03-1.12). CONCLUSIONS: Our findings support a link between HCV and PTDM.

Evaluación de la percepción de las barreras en la asistencia sanitaria y del impacto de las inyecciones intravítreas en la degeneración macular asociada a la edad neovascular / AEvaluación de la percepción de las barreras en la asistencia sanitaria y del impacto de las inyecciones intravítreas en la degeneración macular asociada a la edad neovascular

Propósito Evaluar la percepción de las barreras en la asistencia sanitaria y del impacto de las inyecciones intravítreas en los pacientes con degeneración macular asociada a la edad neovascular (DMAEn). Métodos Estudio transversal de 108 pacientes con DMAEn en tratamiento con inyecciones intravítreas mediante un cuestionario de 26 preguntas (puntuación del 1 al 5) divididas en 3 bloques: 1)enfermedad y su tratamiento con inyecciones; 2)barreras en la asistencia sanitaria, y 3)nuevas tecnologías. Resultados La edad media fue 80,4±7,0 años y la agudeza visual (AV) de 75,2±12,4 letras. Las principales barreras en la asistencia sanitaria fueron los largos tiempos de espera en consulta (72%), seguida por otras comorbilidades (10%). El 63% de los pacientes dedican entre 3 y 5h para acudir a la consulta. Se apreció una ansiedad notable debida a las inyecciones (2,8±1,3), estando presente en el 71% el día antes. Se observó un gran miedo a la ceguera y a dejar de ser independientes (4,4±0,9 y 4,3±1,1), sin existir diferencias en relación con la AV, la edad o el sexo (p≥0,135). El 28% de los pacientes refieren que les cuesta bastante o mucho la asistencia a consulta, presentando el 69% del total un gran interés en tener un aparato diagnóstico en el domicilio. Conclusiones La DMAEn y su tratamiento suponen una importante carga asistencial para los pacientes, existiendo un gran miedo a la ceguera y a perder su independencia, siendo la principal barrera el largo tiempo de espera en consulta (AU)

Aim To evaluate the perception of barriers in healthcare and the impact of intravitreal injections in patients with neovascular age-related macular degeneration (nAMD). Methods Cross-sectional study including 108 patients with nAMD in treatment with intravitreal injections. The patients answered a questionnaire with 26 questions (score from 1 to 5) divided in three sections: 1)the disease and its treatment with injections; 2)healthcare barriers, and 3)new technologies. Result The mean age was 80.4±7.0 years and visual acuity (VA) was 75.2±12.4 letters. The main barriers in healthcare were long waiting times (72%), followed by other comorbidities (10%). Some 63% of patients have to wait between 3 and 5hours to attend their clinical visit. Significant anxiety due to the injections (2.8±1.3) was observed, being present in 71% of the cases the day before. A great fear of blindness and losing independence was observed (4.4±0.9 and 4.3±1.1), with no differences in relation to VA, age or sex (P≥.135). Moreover, 28% of the patients reported that it was quite or very difficult for them to attend the clinical visit, with 69% of the total showing great interest in having a diagnostic device at home.Conclusion The nAMD and its treatment represent a significant burden on patients, among whom there is a great fear of blindness and of losing their independence, the main barrier being the long waiting time for the clinical visit (AU)

Avaliaçäo da somatotropina (BST) em vacas leiteiras / Evaluation of somatotropin (BST) in dairy cows

Utilizaram-se 30 vacas da raça Holandeza, submetidas a três tratamentos: T1 - controle, T2 - BST 320 mg a cada 14 dias e T3 - BST 640 mg a cada 28 dias. A produçäo de leite e gordura e consumo de raçäo foram mensurados. Após um período experimental de 84 dias, evidenciou-se aumento na produçäo de leite de 13,5 por cento (T2) e 17,0 por cento (T3) em relaçäo ao controle (T1). Houve aumento do consumo de raçäo de 4,8 por cento (T2) e 5,8 por cento (T3) em relaçäo ao controle. Os lotes tratados apresentaram aumento na eficiência de utilizaçäo da dieta de 9 por cento (T2) e 11 por cento (T3)