Instrumentos para la evaluación del riesgo de lesiones por presión en adultos en estado crítico: scoping review / Risk assessment instruments for pressure ulcer in adults in critical situation: a scoping review / Instrumentos para a avaliação do risco de lesões por pressão para adultos em situação crítica: scoping review*

Objetivo: mapear los instrumentos para la evaluación del riesgo de lesiones por presión en adultos en situación crítica en una unidad de terapia intensiva; identificar los indicadores de desempeño de los instrumentos y la apreciación de los usuarios con respecto al uso/limitaciones de los instrumentos. Método: scoping review. Para redactar el estudio se utilizó la extensión Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. La investigación se realizó mediante la herramienta de búsqueda EBSCOhost en 8 bases de datos, resultando 1846 estudios, de los cuales 22 conforman la muestra. Resultados: se identificaron dos grandes grupos de instrumentos: los generalistas [Braden, Braden (ALB), Emina, Norton-MI, RAPS y Waterlow]; y los específicos (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi y Sanada y el índice COMHON). En cuanto al valor predictivo, EVARUCI y CALCULATE mostraron los mejores resultados de indicadores de desempeño. En cuanto a las apreciaciones/limitaciones señaladas por los usuarios, destaca la escala CALCULATE, seguida de la EVARUCI y la RAPS-ICU, aunque aún necesitan ajustes futuros. Conclusión: el mapeo mostró que las evidencias son suficientes para indicar uno o más instrumentos para la evaluación del riesgo de lesiones por presión en adultos críticos en una unidad de cuidados intensivos.

Objective: to map the instruments for risk assessment of pressure ulcers in adults in critical situation in intensive care units; identify performance indicators of the instrument, and the appreciation of users regarding the instruments' use/limitations. Method: a scoping review. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews in the writing of the study. We carried out the searches in the EBSCOhost search tool for 8 databases, resulting in 1846 studies, of which 22 studies compose the sample. Results: we identified two big instrument groups: generalist [Braden, Braden (ALB), Emina, Norton-MI, RAPS, and Waterlow]; and specific (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi and Sanada, and COMHON index). Regarding the predictive value, EVARUCI and CALCULATE presented better results for performance indicators. Concerning appreciation/limitations indicated by users, we highlight the CALCULATE scale, followed by EVARUCI and RAPS-ICU, although they still need future adjustments. Conclusion: the mapping of the literature showed that the evidence is sufficient to indicate one or more instruments for the risk assessment of pressure ulcers for adults in critical situation in intensive care units.

Objetivo: mapear os instrumentos para avaliação do risco de lesões por pressão nos adultos em situação crítica em unidade de cuidados intensivos; identificar os indicadores de desempenho dos instrumentos e a apreciação dos utilizadores quanto ao uso/às limitações dos instrumentos. Método: scoping review. O Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews foi utilizado para a redação do estudo. A pesquisa foi realizada na ferramenta de busca EBSCOhost em oito bases de dados, resultando em 1846 estudos, dos quais 22 compõem a amostra. Resultados: identificaram-se dois grandes grupos de instrumentos: os genéricos [Braden, Braden (ALB), Emina, Norton-MI, RAPS e Waterlow]; e os específicos (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi e Sanada e o índice de COMHON). Quanto ao valor preditivo, a EVARUCI e a CALCULATE apresentaram os melhores resultados de indicadores de desempenho. Em relação à apreciação/às limitações apontadas pelos utilizadores, destacam-se a escala CALCULATE, seguindo-se da EVARUCI e da RAPS-ICU, embora ainda necessitem de ajustes futuros. Conclusão: o mapeamento mostrou que as evidências são suficientes para indicar um ou mais instrumentos para avaliação do risco de lesões por pressão nos adultos em situação crítica em unidade de cuidados intensivos.

Risk assessment instruments for pressure ulcer in adults in critical situation: a scoping review. / Instrumentos para la evaluación del riesgo de lesiones por presión en adultos en estado crítico: scoping review.

OBJECTIVE: to map the instruments for risk assessment of pressure ulcers in adults in critical situation in intensive care units; identify performance indicators of the instrument, and the appreciation of users regarding the instruments' use/limitations. METHOD: a scoping review. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews in the writing of the study. We carried out the searches in the EBSCOhost search tool for 8 databases, resulting in 1846 studies, of which 22 studies compose the sample. RESULTS: we identified two big instrument groups: generalist [Braden, Braden (ALB), Emina, Norton-MI, RAPS, and Waterlow]; and specific (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi and Sanada, and COMHON index). Regarding the predictive value, EVARUCI and CALCULATE presented better results for performance indicators. Concerning appreciation/limitations indicated by users, we highlight the CALCULATE scale, followed by EVARUCI and RAPS-ICU, although they still need future adjustments. CONCLUSION: the mapping of the literature showed that the evidence is sufficient to indicate one or more instruments for the risk assessment of pressure ulcers for adults in critical situation in intensive care units. (1) The risk assessment instrument must be applied to the patient's specificities. (2) The instruments are divided into two groups: generalist and specific. (3) The EVARUCI and CALCULATE instruments presented better results. (4) The EVARACI presented better results in terms of performance indicators. (5) The CALCULATE highlights itself for being recent scale, appropriate, simple, and easy to use.

Endocarditis Presenting as Right Atrial Mass, Diagnosed with 18F-Fluorodeoxyglucose-PET: A Case Report.

We report a case of a 55-year-old male with a history of methicillin-resistant staphylococcus aureus bacteremia whose initial transesophageal echocardiography revealed a cardiac mass attached to the right atrium. Because of the uncommon location of the mass, 18F-fluorodeoxyglucose-PET was used to confirm the diagnosis of infective endocarditis.

Detection of pancreatic cancer by convolutional-neural-network-assisted spontaneous Raman spectroscopy with critical feature visualization.

Pancreatic cancer is the deadliest cancer type with a five-year survival rate of less than 9%. Detection of tumor margins plays an essential role in the success of surgical resection. However, histopathological assessment is time-consuming, expensive, and labor-intensive. We constructed a lab-designed, hand-held Raman spectroscopic system that could enable intraoperative tissue diagnosis using convolutional neural network (CNN) models to efficiently distinguish between cancerous and normal pancreatic tissue. To our best knowledge, this is the first reported effort to diagnose pancreatic cancer by CNN-aided spontaneous Raman scattering with a lab-developed system designed for intraoperative applications. Classification based on the original one-dimensional (1D) Raman, two-dimensional (2D) Raman images, and the first principal component (PC1) from the principal component analysis on the 2D image, could all achieve high performance: the testing sensitivity, specificity, and accuracy were over 95%, and the area under the curve approached 0.99. Although CNN models often show great success in classification, it has always been challenging to visualize the CNN features in these models, which has never been achieved in the Raman spectroscopy application in cancer diagnosis. By studying individual Raman regions and by extracting and visualizing CNN features from max-pooling layers, we identified critical Raman peaks that could aid in the classification of cancerous and noncancerous tissues. 2D Raman PC1 yielded more critical peaks for pancreatic cancer identification than that of 1D Raman, as the Raman intensity was amplified by 2D Raman PC1. To our best knowledge, the feature visualization was achieved for the first time in the field of CNN-aided spontaneous Raman spectroscopy for cancer diagnosis. Based on these CNN feature peaks and their frequency at specific wavenumbers, pancreatic cancerous tissue was found to contain more biochemical components related to the protein contents (particularly collagen), whereas normal pancreatic tissue was found to contain more lipids and nucleic acid (particularly deoxyribonucleic acid/ribonucleic acid). Overall, the CNN model in combination with Raman spectroscopy could serve as a useful tool for the extraction of key features that can help differentiate pancreatic cancer from a normal pancreas.

Detection and analysis of enamel cracks by ICG-NIR fluorescence dental imaging.

Cracked teeth are the third most common cause of tooth loss, but there is no reliable imaging tool for the diagnosis of cracks. Here, we demonstrate the feasibility of indocyanine green near-infrared fluorescence (ICG-NIRF) dental imaging for the detection of enamel cracks and enamel-dentin cracks in vitro in the first (ICG-NIRF-I, 700-950 nm) and second (ICG-NIRF-II, 950-1700 nm) imaging windows with transmission excitation light, and compared ICG-NIRF with conventional NIR illumination-II (NIRi-II) and X-ray imaging. Dentin cracks were detected by CT scan, while most enamel cracks, undetectable under X-ray imaging, were clearly visible in NIR images. We found that ICG-NIRF-II detected cracks more effectively than NIRi-II, and that light orientation is an important factor for crack detection: an angled exposure obtained better image contrast of cracks than parallel exposure, as it created a shadow under the crack. Crack depth could be evaluated from the crack shadow in ICG-NIRF and NIRi-II images; from this shadow we could determine crack depth and discriminate enamel-dentin cracks from craze lines. Cracks could be observed clearly from ICG-NIRF images with 1-min ICG tooth immersion, although longer ICG immersion produced images with greater contrast. Overall, our data show that ICG-NIRF dental imaging is a useful tool for diagnosing cracked teeth at an early stage.

Optimal imaging windows of indocyanine green-assisted near-infrared dental imaging with rat model and its comparison to X-ray imaging.

In this study, we used rat animal model to compare the efficiency of indocyanine green (ICG)-assisted dental near-infrared fluorescence imaging with X-ray imaging, and we optimized the imaging window for both unerupted and erupted molars. The results show that the morphology of the dental structures was observed clearly from ICG-assisted dental images (especially through the endoscope). A better image contrast was easily acquired at the short imaging windows (<10 minutes) for unerupted and erupted molars. For unerupted molars, there is another optimized imaging window (48-96 hours) with a prominent glow-in-the-dark effect: only the molars remain bright. This study also revealed that the laser ablation of dental follicles can disrupt the molar development, and our method is able to efficiently detect laser-treated molars and acquire the precise morphology. Thus, ICG-assisted dental imaging has the potential to be a safer and more efficient imaging modality for the real-time diagnosis of dental diseases.

Improvement of cell deposition by self-absorbent capability of freeze-dried 3D-bioprinted scaffolds derived from cellulose material-alginate hydrogels.

Cell-laden printing is the most commonly used approach in 3D bioprinting. One of the major drawbacks of cell-laden printing is that cell viability is highly affected by the extrusion pressure and shear force in the printing process. We present a new cell-deposition method by using the superabsorbent capability of 3D printed scaffolds with four ink formations: 20:10 nanocrystal/alginate (NCA 20/10), 20:10 nanofiber/alginate (NFA 20/10), 20:02 nanocrystal/alginate (NCA 20/02) and 20:02 nanofiber/alginate (NFA 20/02). Limited pores were observed from the surface of inherent NCA and NFA scaffolds, which may limit the numbers of cells to enter into the scaffolds. Therefore, we designed a dual-porous (DP) structure to connect the inherent pores (IPs) to the scaffold surface. Due to these porous structures, NCA and NFA scaffolds exhibit an excellent capability to absorb cell suspension, which may be used for depositing cells to 3D-printed scaffolds, namely self-absorbent (SA) deposition. Compared to the conventional top-loading (TL) method, the SA method had more uniform cell distributions in the entire 3D-printed scaffolds and higher efficiency of cell deposition. For the TL method, DP scaffold exhibited a more uniform cell distribution, which may provide a better microenvironment for the cells in comparison to the IP scaffold. For both cell loading methods, a rapid increase of cell number was observed in the first 4 days of culture in the 3D-printed NCA and NFA structures. NFA 20/02 exhibits the best cell viability compared to the other three inks. In conclusion, the SA method may serve as a new approach for loading cells in cell-free 3D-bioprinting, and DP design could improve the efficiency of the cell deposition.

Expression of microRNAs targeting heat shock protein B8 during in vitro expansion of dental pulp stem cells in regulating osteogenic differentiation.

OBJECTIVE: The objectives of this study were (a) to determine the differentially expressed microRNAs that can target heat shock protein B8 (HspB8) during in vitro expansion of dental pulp stem cells (DPSCs); (b) to identify microRNAs involved in posttranscriptional regulation of HspB8 expression; and (c) to determine if HspB8-targeting microRNAs play roles on osteogenic differentiation of DPSCs. DESIGN: DPSCs were established from rat first molars and expanded in vitro until the passage that cells lost osteogenic potential. TargetScan was used to predict the microRNAs that target HspB8 mRNA. Stem-loop quantitative RT-PCR was conducted to identify the HspB8-targeting microRNAs that were upregulated in late passages. The microRNAs mimics were transfected into DPSCs to assess their effects on HspB8 expression and on osteogenic differentiation. RESULTS: let-7b-5p, miR-98-5p, miR-215, miR-219a-1-3p and miR-295-5p were found to consistently increase expression in DPSCs after expansion. HspB8 mRNA and/or protein were significantly decreased in the DPSCs after transfection of miR-215 and miR-219a-1-3p mimics; whereas no significant reduction was seen after transfecting let-7b-5p, miR-98-5p and miR-295-5p mimics. When subjecting the transfected DPSCs to osteogenic induction, reduction of calcium deposition or osteogenic marker expression were observed with miR-215, miR-219a-1-3p and miR-295-5p transfection. CONCLUSIONS: Increased expression of miR-215 and miR-219a-1-3p downregulates HspB8 expression, which contributes to the reduction of osteogenic capability of DPSCs. Increased expression of miR295-5p also causes a reduction of osteogenic differentiation, but not involved in HspB8.

Indocyanine green-assisted dental imaging in the first and second near-infrared windows as compared with X-ray imaging.

Indocyanine green (ICG) has been widely used in medical imaging, such as in retinal angiography. Here, we describe a pilot ex vivo study of ICG-assisted near-infrared fluorescence (NIRF) dental imaging in the first (700-950 nm for ICG-NIRF-I) and second (1000-1700 nm for ICG-NIRF-II) NIR windows using human extracted teeth; our study is compared with the traditional prevalent X-ray imaging and NIR II illumination (NIRi-II, 1310 nm) without ICG enhancement. The results show that ICG fluorescence has much better imaging contrast in both windows compared with NIRi-II (by quantitatively comparing NIR intensity of the critical neighboring structures, such as enamel and dentin). Cracked teeth, notoriously hard to diagnose by dental X-ray and computed tomography, were clearly profiled in NIRF dental imaging. An insidious occlusal caries, missing in X-ray imaging, became a bright dot that was readily observed in ICG-NIRF-I images. For dental decay, NIRF imaging with ICG enhancement could clearly delineate the decay boundary. NIRF in both windows distinguished interproximal and occlusal superficial caries. Overall, ICG-assisted NIRF dental imaging has unique advantages in identifying cracked teeth and insidious caries. The two NIR imaging windows used in our study might one day serve as noninvasive and nonionizing-radiation methods for the diagnosis of critical dental diseases in situ.

Acute bivalvular left-sided methicillin-resistant Staphylococcus aureus endocarditis with cardiac, cerebral, renal and septic complications.

Infective endocarditis (IE) is now rare in developed countries, but its prevalence is higher in elderly patients with prosthetic valves, diabetes, renal impairment, or heart failure. An increase in health-care associated IE (HCAIE) has been observed due to invasive maneuvers (30% of cases). Methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus are the most common agents in HCAIE, causing high mortality and morbidity. We review complications of IE and its therapy, based on a patient with acute bivalvular left-sided MRSA IE and a prosthetic aortic valve, aggravated by congestive heart failure, stroke, acute immune complex glomerulonephritis, Candida parapsilosis fungémia and death probably due to Serratia marcescens sepsis. The HCAIE was assumed to be related to three temporally associated in-hospital interventions considered as possible initial etiological mechanisms: overcrowding in the hospital environment, iv quinolone therapy and red blood cell transfusion. Later in the clinical course, C. parapsilosis and S. marcescens septicemia were considered to be possible secondary etiological mechanisms of HCAIE.

Acute myocardial infarction associated with anomalous origin of coronary arteries (a rare case of origin of the left coronary artery from the ostium of the right coronary artery).

Origin of the left coronary artery from the ostium or proximal segment of the right coronary artery (single coronary artery) is a rare congenital anomaly (0.03 to 0.4%) and an unusual angiographic finding (0.6 to 1.3%). The most common congenital anomaly is separate origin of the left anterior descending artery and circumflex artery from the left coronary sinus. The second most common anomaly is the origin of the circumflex artery from the right coronary sinus. We present a patient with acute inferior myocardial infarction and cardiogenic shock, in whom it was not possible to perform catheterization of the left coronary artery because of the absence of the ostium of the left coronary sinus. Multislice computed tomography of the coronary arteries was the tool that enabled us to visualize the origin and course of the left coronary artery.

Aortic and tricuspid endocarditis due to Streptococcus gallolyticus in an immunocompetent patient with a normal heart.

Endocarditis due to Streptococcus gallolyticus, an agent previously included in the Streptococcus bovis denomination is a serious disease, often associated with lesions of the colon mucosa. Aortic valve is more often affected and tricuspid involvement is quite rare. We present a case of a 56-year-old man who was admitted with a 2-month history of fever. Echocardiogram revealed vegetations on the aortic and tricuspid valve and blood cultures grew S. gallolyticus. Thoracic X-ray and computed tomography were consistent with septic pulmonary embolism. Despite optimal antibiotic therapy he developed an ischemic stroke and acute aortic regurgitation, which led to emergent surgery. Colonoscopy found a benign adenoma which was excised, and the patient had a full recovery.

Percutaneous aortic valvuloplasty in inoperable symptomatic severe aortic stenosis in the very elderly.

Aortic valve replacement is the first therapeutic option in patients with symptomatic severe aortic stenosis. Given the fact that percutaneous aortic valve implantation is a relatively new procedure and the need for palliative treatment in symptomatic patients with a high surgical risk, percutaneous balloon aortic valvuloplasty is still employed. The authors describe two cases of percutaneous balloon aortic valvuloplasty in very elderly patients with severe calcified aortic stenosis not suitable for cardiac surgery, exacerbated in one case by significant coronary artery disease and left ventricular systolic dysfunction. The authors also review the role of this procedure in current interventional cardiology.

Echocardiography in emergency.

The use of echocardiography is still far from optimal. It is difficult or impossible to ensure the 24-hour presence at a hospital of a cardiologist with experience in echocardiography. As a result other specialties are becoming familiar with this technique. Echocardiography has been recognized as of paramount importance in diagnosis, prognosis and therapeutic decisions in several diseases and therefore echocardiographic training with different levels of experience should be supported and coordinated by a reference group in such matters. The authors review some aspects of echocardiography in emergency. They emphasize the importance of continuous training and accreditation as required conditions to perform echocardiography.

Homocysteine increase after acute myocardial infarction--can it explain the differences between case-control and cohort studies?

Several case-control studies agree that elevated homocysteinemia (HC) is a risk factor for cardiovascular disease, particularly for acute myocardial infarction (AMI). However, this agreement does not extend to prospective studies--some of which confirm and others (MRFIT and Karelia) reject this relation. After an AMI there are significant changes in biochemical and laboratory parameters, including a decrease in cholesterolemia, which takes several months to return to baseline levels. The evolution of HC after AMI is still unknown. In this work we set out to evaluate the evolution of homocysteinemia values after acute myocardial infarction. We evaluated fasting homocysteinemia in 34 sequential patients after admission to the Intensive Care Unit and after confirmation of acute myocardial infarction (26 male; mean age 63.8 +/- 13.9 years) in the first 36 hours, between the 3rd and 6th day, and one month after AMI. Simultaneously, we studied traditional risk factors and performed routine laboratory tests. The mean values found for HC were 13.85 +/- 5.46 mol/l in the first 36 hours after AMI, 16.16 +/- 6.63 mol/l between the 3rd and the 6th day, and 16.27 +/- 7.27 mol/l one month after myocardial infarction. The difference between the first and the second, and between the first and the third measurements, was significant (p < 0.05). The HC values found 3-6 days and one month after myocardial infarction were similar (p = 0.88). A highly significant correlation was found between HC values assessed in the first and second (correlation coefficient [CC] = 0.62) and in the second and third measurements (CC = 0.57), both with p = 0.001. We can conclude that HC levels increase significantly 36 hours after an acute myocardial infarction, an increase of around 20%, which is maintained until at least one month after the infarction. In these circumstances the difference in the vascular risk of HC found between case-control and prospective studies may be explained, at least partially, by the HC increase after AMI.