Frailty and risk of complications in head and neck oncologic surgery. Systematic review and dose-response meta-analysis.

BACKGROUND: There is emerging evidence that frail individuals present a decreased physiological reserve, decreased ability to maintain homeostasis, and increased vulnerability to stressors. The concept of frailty has become increasingly recognized as a valuable measure in oncological surgical patients, including those with head and neck cancer. Preoperative screening for frailty may provide an individualized risk assessment that can be used by an interdisciplinary team for preoperative counseling and to improve outcomes. The aim of this meta-analysis was to evaluate the relationship between frailty and the risk of major postoperative complications in frail individuals submitted to head and neck oncologic surgery. MATERIAL AND METHODS: PubMed, SCOPUS, Web of Science, Google Scholar and OpenThesis were systematically searched to identify studies that evaluated the risk of major postoperative complications in frail individuals undergoing head and neck oncologic surgery. The search was performed on August 31, 2020, without language or date restrictions. Two independent investigators screened the searched studies based on each paper's title and abstract. Relevant studies were read in full and selected according to the eligibility criteria. Frailty was assessed by modified Frailty Index (mFI-11) and major postoperative complications were measured by the Clavien-Dindo classification. We performed a categorical and dose-response meta-analysis using a random-effects model to evaluate the association between frailty and the risk of major postoperative complications in patients submitted to head and neck oncologic surgery. The results of the meta-analysis were expressed as relative risk (RR) and 95% confidence interval (95% CI). The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS: Four studies (9,947 patients) were included in this systematic review and meta-analysis. Frail patients presented an increased risk of life-threatening complications requiring intensive care unit (ICU) admission (RR = 4.67; 95% CI 1.54-14.10) and 30-day mortality (RR = 8.10; 95% CI 2.30-28.57) compared to non-frail patients. We found evidence of dose-response trend between mFI-11 and major postoperative complications. CONCLUSIONS: Higher frailty scores are associated with a significant increase in ICU-level complications and 30-day mortality after head and neck oncologic surgery.

Avaliação do impacto do tempo de espera para admissão em Unidade de Terapia Intensiva no desfecho clínico do paciente crítico / Assessment of the impact of waiting time until admission in the Intensive Care Unit on the clinical outcome of critical patients

RESUMO: Este estudo tem por base a premissa de que com um maior número de leitos de Unidade de Terapia Intensiva (UTI) disponíveis o tempo de espera para admissão em UTI é menor, o que resulta no melhor desfecho clínico, justifi-cando, portanto, a importância do presente estudo. Objetivo: Avaliar se o tempo de espera no Departamento de Emergência até a admissão em UTI tem influência no desfecho clínico do paciente crítico. Metodologia: Estudo ob-servacional, retrospectivo, do tipo antes e depois, realizado em um hospital público do município de Joinville/SC no ano de 2019. Foram incluídos os dados referentes aos pacientes adultos admitidos na UTI com até 72 horas de es-pera no Departamento de Emergência desde a chegada ao hospital. Comparou-se o último trimestre de 2017 (fase 1), período durante o qual havia 14 leitos de UTI no hospital, e último trimestre de 2018 (fase 2), período durante o qual havia 30 leitos de UTI. Resultados: Analisaram-se 173 prontuários elegíveis de 2017 e 2018. Houve diferen-ça estatisticamente significativa no tempo decorrido na emergência até a admissão em UTI entre 2017 e 2018 (me-diana de 22 vs. 15; p=0,0002). A diferença estatística também foi relevante para a mortalidade em até 24 horas após a admissão em UTI, comparando-se os dois anos em questão (9,61% vs. 2,47%; p=0,04). Não houve diferen-ça estatística significante na mortalidade hospitalar entre 2017 e 2018 (34,6% vs. 35,5%; p=0,57). Também não houve diferença estatisticamente relevante entre os demais parâmetros analisados. Conclusão: Comparando-se 2017 a 2018, percebeu-se que o tempo de espera pelo leito de UTI diminuiu, bem como a mortalidade em até 24h da admissão intensiva. No entanto, isto não se refletiu na mortalidade hospitalar. (AU)

ABSTRACT: The premise that underpins this study is that the more Intensive Care Unit (ICU) beds available, the shorter the waiting time for ICU admission, resulting in better clinical outcomes, which justifies the relevance of this study. Objective: Assess if the waiting time in the Emergency Room until ICU admission influences on the clinical outcome of critical patients. Methods: An observational longitudinal retrospective study performed in a public hospital in Joinville/SC in 2019. This study analyzed data from patients admitted to the ICU with up to 72h of waiting time in the Emergency Room. It compares Q4'2017 (phase 1), when there were 14 ICU beds in the hospital vs. Q4'2018 (phase 2), when there were 30 ICU beds. Results: 173 medical records were analyzed in 2017-2018. There was a statistically significant difference in the time for ICU admission between 2017 and 2018 (median 22h vs. 15h; p=0.0002). There was also a statistically significant difference for mortality rates up to 24h of admission (9.61% vs. 2.47%; p=0.04). There was no statistically significant difference for hospital mortality rates (34.6% vs. 35.5%; p=0.57). There was also no statistically significant difference between the other parameters analyzed. Conclusion:Comparing 2017 and 2018, waiting time for an ICU bed was shorter in 2018, and the mortality rates up to 24 hours of ICU admission were lower. However, waiting time in the Emergency Room until ICU admission did not show as-sociation with hospital mortality rates. (AU)

Efficacy of proteolytic enzyme bromelain on health outcomes after third molar surgery. Systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Bromelain is a cysteine protease isolated from pineapple with a range of biological properties including platelet aggregation inhibition and anti-inflammatory effects. Recent studies have evaluated the clinical implications of bromelain in reducing postoperative inflammatory complications after third molar surgery, but the results are contrasting. This systematic review and meta-analysis evaluated the effects of bromelain on health outcomes in patients submitted to third molar surgery. MATERIAL AND METHODS: The study was conducted following the PRISMA statement. Searches were conducted in six electronic databases and Google Scholar from inception to May 2018. The following elements were used to define eligibility criteria: (1) population: patients undergoing third molar surgery; (2) intervention and controls: bromelain vs placebo or no-treatment control group; (3) outcomes: quality of life, postoperative pain, rescue analgesic consumption, facial swelling, and trismus; and (4) study type: randomized clinical trials (RCTs). Treatment effects were defined as weighted (WMD) or standardized mean difference (SMD) and 95%CIs. RESULTS: Six RCTs were included in the meta-analysis. There was large effect size of bromelain on improving physical appearance (SMD -0.77, CI% 95 -1.11 to -0.42), social isolation (SMD -0.97, CI% 95 -1.74 to -0.21), and sleep quality (SMD -1.19, CI% 95 -1.97 to -0.40) during the first postoperative week. Differences in pain intensity were found during the first 24h (SMD -0.49, CI 95% -0.82 to -0.17) and 7 days after surgery (SMD -0.52, CI 95% -0.79 to -0.24). No evidence was found that bromelain was effective in reducing trismus and facial swelling. CONCLUSIONS: The currently available evidence suggests that bromelain has a beneficial effect in reducing pain and has a positive impact on patient quality of life after third molar surgery. However, therapeutic advances for the use of bromelain need a high level of evidence and further head-to-head RCTs are needed to inform clinical choices.

Successful prevention of tunneled central catheter infection by antibiotic lock therapy using cefazolin and gentamicin.

Catheter-related bacteremia (CRB) is one of the various complications related to hemodialysis (HD). As a result of this high rate of infection, the antibiotic lock technique (ALT) has been recommended to prevent CRB. However, adverse effects of ALT such as increased emergence of strains resistant to antibiotics and increased mechanical dysfunction catheter were poorly evaluated. We prospectively evaluated the efficacy of catheter-restricted filling using an antibiotic lock solution in preventing CRB. A total of 233 HD patients requiring 325 new tunneled catheters while waiting for placement and maturation of an arteriovenous fistula or graft were enrolled in this study. Patients with a tunneled catheter were assigned to receive either an antibiotic-heparin lock solution (antibiotic group: cefazolin 10 mg/ml, gentamicin 5 mg/ml, heparin 1,000 U/ml) or a heparin lock solution (no-antibiotic group: heparin 1,000 U/ml) as a catheter lock solution during the interdialytic period. The present study aimed to assess the efficacy of ALT using cefazolin and gentamicin in reducing CRB in patients undergoing HD with tunneled central catheter and to identify its adverse effects. CRB developed in 32.4 % of patients in the no-antibiotic group and in 13.1 % of patients in the antibiotic group. CRB rates per 1,000 catheter-days were 0.57 in the antibiotic group versus 1.74 in the no-antibiotic group (p < 0.0001). Kaplan-Meier analysis also showed that mean CRB-free catheter survival was significantly higher in the antibiotic group than in the no-antibiotic group (log-rank statistic 17.62, p < 0.0001). There was statistically significant difference between the two groups in causative organisms of CRB, with predominance of negative culture in both groups, but this prevalence was higher in ALT group (57.9 vs 90.1 %, p < 0.0001), and the two groups also were different in prevalence of gram-positive bacteria as causing organisms (ALT group 21.05 vs = 0 % in control group, p < 0.0001). There was no statistically significant difference between the two groups in drug-resistant germs. There were statistically significant differences between the two groups in the catheter removal causes, with higher rate of infectious cause in control group (12.32 vs 2.22 %, p < 0.0001) and mechanical cause in ALT group (28.26 vs 37.78 %, p < 0.0001). The results suggest that ALT may be a beneficial means of reducing the CRB rate in HD patients with tunneled catheter, without association between ALT and emergence of strains resistant. However, mechanical complications were more prevalent in antibiotic group. Further studies are required to determine the optimal drug regimen, concentrations for ALT, and its adverse effects.

Meloidogyne javanica on Peanut in Florida.

A mixed population of Meloidogyne arenaria race 1 and M. javanica race 3 is reported on peanut from a field in Levy County, Florida. Confirmation of M. javanica on peanut is based on esterase and malate dehydrogenase isozyme patterns resolved on polyacrylamide slab gels following electrophoresis, and perineal patterns. Up to 29% of 290 individual females collected from peanut roots in the field in autumn 2002 showed a typical esterase J3 phenotype for M. javanica. This is the third report of M. javanica infecting peanut in the United States.

Sulfation of intrinsic glycoproteins of the rabbit vitreous.

The experiments reported here were designed to characterize the intrinsic vitreous glycoproteins and to understand the process of their sulfation. Rabbits were injected intravitreally with 35S-sodium sulfate and killed at several time intervals after injection. In another series of experiments, rabbits were injected either with 35S-sodium sulfate, 3H-fucose or 3H-tyrosine, associated or not associated with tunicamycin administration. Vitreous from the control eyes was also digested with N-glycosidase. Furthermore, ciliary bodies, the putative source of the intrinsic vitreous glycoproteins, were incubated with 35S-sodium sulfate in the presence or absence of the protein synthesis inhibitor cycloheximide, and the culture media recovered for analysis. These and the vitreous samples of the other experiments were processed for sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and fluorography. Except for serum albumin, practically all polypeptide bands of the vitreous and culture media were labeled with radioactive sulfate and were shown to undergo renewal. The experiments using tunicamycin or enzyme treatment suggest that radioactive sulfate was incorporated not only into the carbohydrate side chains of the glycoproteins but also into the amino acid tyrosine of the polypeptide backbone of these glycoproteins.

Medical care in old age: what do nurses in long-term care consider appropriate?

OBJECTIVES: To determine whether nurses working in a long-term care institution, who are knowledgeable about the full range of conditions common among older people, favor limitations of treatment in old age; and to study whether the level of intensity of care they regard as appropriate varies with the overall health status of the older individual. DESIGN: Participants were asked to complete an intervention-specific advance directive for themselves, with scenarios representing terminal illness, dementia plus chronic illness, chronic illness in a nursing home resident, chronic illness in a community-dwelling older person, and a robust, community-dwelling older person. SETTING: A 725-bed long-term care institution, with residents having a mean age of 88 years and a wide range of physical and cognitive deficits. PARTICIPANTS: Full-time nurses at the long-term care facility were eligible and were given survey instruments; 102 of the 145 eligible nurses completed the questionnaire. MEASUREMENTS: The unit of analysis is the refusal rate, defined as the mean number of refusals of interventions for each respondent. MAIN RESULTS: The overall refusal rate for all five scenarios taken together was 72.1%. The refusal rate in the case of terminal illness was 90.9%, in the case of dementia plus chronic illness 81.8%, in the case of dementia in a nursing home 69.1%, for a homebound older person with chronic illness 70.9%, and for a previously healthy 85-year-old person living in the community, 50.0% (P < .001). CONCLUSIONS: Nurses working in a long-term care institution have strong preferences about limiting a variety of interventions in old age. The greater the degree of physical and cognitive impairment, the more limitations they favor. This suggests the necessity of expanding advance planning to include a discussion of what constitutes appropriate treatment in a broad range of circumstances.

Interleukin-1 and interleukin-2 defects associated with murine graft-versus-host-induced immunodeficiency.

In this study we investigated the mechanism, or mechanisms, involved in graft-versus-host (GVH)-induced T cell immunodeficiency. Chronic GVH reactions were induced in normal CBA X A F1 (BAF1) hybrid mice by the injection of parental A strain lymphoid cells. At various times (43-91 days) after GVH induction, the functional status of GVH T cells was assessed using interleukin-1 (IL-1) and interleukin-2 (IL-2) as probes. The response of GVH thymocytes to IL-1 was depressed when compared with normal thymocytes. Although GVH peanut-agglutinin-negative (PNA-) thymocytes did respond to IL-2 alone or IL-2 plus phytohemagglutinin (PHA), this response was significantly lower than the response of PNA- thymocytes from normal mice. In addition, GVH spleen cells failed to produce significant amounts of IL-2 when stimulated with concanavalin A. These results suggest that the long term immunosuppression associated with murine chronic GVH disease is due, at least in part, to a decrease in the responsiveness to IL-1 and IL-2, and to a marked deficiency in IL-2 production.