Clinical challenges of glycemic control in the intensive care unit: A narrative review.

Glucose control in patient admitted to the intensive care unit has been a topic of much debate over the past 20 years. The harmful effects of uncontrolled hyperglycemia and hypoglycemia in critically ill patients is well established. Although a large clinical trial in 2001 demonstrated significant mortality and morbidity benefits with tight glucose control in this patient population, the results could not be replicated by other investigators. The "Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation" trial in 2009 established that tight glucose control was not only of no benefit, but in fact harmful due to the significant risk of hypoglycemia. The current guidelines suggest a moderate approach with the initiation of intravenous insulin therapy in critically ill patients when the blood glucose level is above 180 mg/dL. The most important factor that underpins glycemic management in intensive care unit patients is the consequent prevention of hypoglycemia. Robust glucose monitoring strategies and insulin protocols need to be implemented in order to achieve this goal.

Expert Consensus Decision Pathway of the American College of Cardiology on Management of Bleeding in Patients With Oral Anticoagulants: A Review of the 2020 Update for Perioperative Physicians.

The use and evolution of oral anticoagulation therapies continue to advance for multiple reasons, including a growing segment of older patients with associated chronic prothrombotic illnesses including cardiovascular, pulmonary, hematologic and oncologic conditions. Correlated to this increased use of oral anticoagulants is bleeding complications associated with their use. Based on these trends, it is expected that perioperative physicians will be facing more and more of these patients requiring scheduled, urgent or emergent surgical procedures During May 2020, the American College of Cardiology updated its Expert Consensus Decision Pathway devoted to the approach of bleeding in patients on oral anticoagulants. This updated version emphasized the expanding role of the direct-acting oral anticoagulants in other conditions beyond nonvalvular atrial fibrillation, such as venous thromboembolism. Several details discussed within this most recent update are pertinent to perioperative physicians, who frequently deal with bleeding in the setting of anticoagulation. The purpose of this narrative review is to highlight and expand on these salient points because they relate to perioperative management.

Quality of life and cognitive and functional performance of octogenarians and nonagenarians undergoing hemodialysis.

OBJECTIVE: To evaluate the quality of life, cognitive and functional capacity of older adult patients undergoing hemodialysis who are 80 years of age or older and compare them to older adults without chronic kidney disease (CKD) treated at a geriatrics outpatient clinic. METHOD: First, 103 older adult patients undergoing hemodialysis and 103 older adults without CKD matched by gender and age were evaluated. Cognitive aspects as evaluated by the mini mental state examination, the Boston Naming Test and verbal fluency were analyzed; comorbidities according to the Charlson's comorbidity index; social support through the Medical Outcomes Study scale; functional ability through the chair sit-to-stand and gait speed tests, as well as the basic activities of daily living (BADL) and instrumental activities of daily living (IADL) and quality of life according to the Kidney Disease Quality of Life Short Form (KDQOL SF-36) questionnaires. RESULTS: The hemodialysis group had a higher rate of comorbidities (7.8 ± 2.4 vs. 5.8 ± 2.3, p < 0.001). In the multiple logistic regression analysis, the group undergoing hemodialysis presented a ninefold greater chance of dependence for IADL than controls, a 4.3 and 3.2 times greater chances for inadequacy on the gait speed and chair sit-to-stand tests, respectively, as well as a 4.4-fold higher risk of cognitive decline on the verbal fluency test. CONCLUSION: Long-lived patients undergoing hemodialysis presented worse quality of life and functional and cognitive performance compared to long-term patients attended at the outpatient clinic, indicating that preventive and protective measures should be considered and implemented.

Community structure and species composition of a periodically flooded Restinga forest in Caraguatatuba, São Paulo, Brazil / Estrutura e composição de espécies de uma floresta de Restinga periodicamente alagada em Caraguatatuba, São Paulo, Brasil

Abstract: The aim of this study was to characterize the structure and composition of the tree and shrub community in a 77-ha fragment of Restinga forest in Caraguatatuba, São Paulo, Brazil. In this fragment, forty 20 × 20-m plots (1.6 ha) were systematically allocated and all trees with a stem diameter at breast height (DBH) ≥4.8 cm were sampled. Sixteen plots were randomly chosen to also sample individuals with a DBH of between 1 and 4.8 cm. All individuals were tagged, identified to species level, and their diameters and heights were measured. A total of 2587 individuals (1616 ind./ha) from 119 species and 42 families were found with a DBH >4.8 cm, and 2659 individuals (4154 ind./ha) from 125 species and 38 families were found with a DBH >1 cm. The richest families were Myrtaceae, Lauraceae, and Fabaceae, and the most abundant species were Diospyros brasiliensis (Ebenaceae), Anaxagorea dolichocarpa (Annonaceae), and Euterpe edulis (Arecaceae). The structure of the studied site was similar to that of other Restinga forest sites, but the forest composition was quite distinct. Implications for the conservation and restoration of Restinga forests in this region are discussed in light of the results obtained.

Resumo: O objetivo deste estudo foi caracterizar a estrutura e composição da comunidade arbórea e arbustiva em um fragmento de 77 ha de floresta de Restinga em Caraguatatuba, São Paulo. Neste fragmento, 40 parcelas de 20 × 20 m (1,6 ha) foram distribuídas sistematicamente e todas as árvores com diâmetro do tronco na altura do peito (DAP) ≥4,8 cm foram amostradas. Além disso, 16 parcelas foram escolhidas aleatoriamente para amostrar também todos os indivíduos com DAP entre 1 e 4.8 cm de DAP. Todos os indivíduos foram marcados, identificados ao nível de espécie e tiveram seu diâmetro e altura medidos. Para indivíduos acima de 4,8 cm de DAP, foi amostrado um total de 2587 indivíduos (1616 ind./ha) em 119 espécies e 42 famílias. Para indivíduos acima de 1 cm de DAP, foi amostrado um total de 2659 indivíduos (4154 ind./ha) em 125 espécies e 38 famílias. As famílias mais ricas foram Myrtaceae, Lauraceae e Fabaceae. As espécies mais abundantes foram Diospyros brasiliensis, Anaxagorea dolichocarpa e Euterpe edulis. Quando comparado com outros locais de florestas de Restinga, a estrutura florestal do fragmento estudado é semelhante a outras florestas de Restinga. No entanto, a composição da floresta é bastante distinta, evidenciando a heterogeneidade das florestas de Restinga ao longo da costa do Brasil. Implicações para a conservação e restauração das florestas de Restinga são destacadas.

Evaluation of quality of life, physical, and mental aspects in longevous patients with chronic kidney disease.

PURPOSE: The diagnosis of chronic kidney disease (CKD) in elderly individuals has been increasing. The objective of this study was to evaluate physical, mental and social aspects in longevous elderly patients with CKD. METHODS: Eighty patients with CKD (stage 4 and 5, not on dialysis) and 60 longevous elderly (≥ 80 years) paired by gender and age living in the community were evaluated. Physical, cognitive, social and quality of life aspects were analyzed according to the following scales: Charlson comorbidity index, Medical Outcomes Study Short Form 36-Item (SF-36), Medical Outcomes Study, Boston Naming Test, verbal fluency test (animal naming), sit-to-stand test, gait speed, and the Mini-Mental state examination. RESULTS: Compared to the control group, the CKD group had a higher mean in the comorbidities index (3.5 ± 1.2 vs. 1.0 ± 1, respectively, p < 0.001). In the multivariate analysis, the CKD group presented worse performance in the SF-36 dimensions: 'physical functioning,' 'general health,' 'emotional functioning,' 'vitality,' and physical component summary. On the other hand, they presented better results for the 'mental health' dimension, in addition to lower  social support, worse verbal fluency and worse results on the sit-to-stand test. CONCLUSIONS: Longevous patients with stage 4 or 5 CKD presented worse evaluation in several domains of physical and emotional functioning, lower social support and evidence of worse cognitive performance. These aspects should be taken into account in order to improve the care provided to these patients, improve their quality of life and prevent their morbidity.