The Hierarchy of Communication Needs: A Novel Communication Strategy for High Mistrust Settings Developed in a Brazilian COVID-ICU.

Context: The COVID-19 pandemic presented unique challenges for health care systems. Overcrowded units, extreme illness severity, uncertain prognoses, and mistrust in providers resulted in a "pressure cooker" where traditional communication strategies were often insufficient. Objectives: Building on well-studied traditional communication interventions, neurobiology principles were used to create a novel communication strategy designed in the COVID-ICU to respond to the unique communication needs of patients within the context of a high mistrust setting. Methods: The hierarchy of communication needs recognizes three specific levels of communication that are essential within high-emotion and low-trust settings. The first level is to establish trust. The second level is to resonate with patients' emotions, helping to reduce arousal and improve empathy. The third level includes the more traditional content of disclosing prognostic information and shared decision-making. When facing communication challenges, clinicians are taught to move back a level and reattune to emotions and/or reestablish trust. Discussion: The COVID pandemic revealed the shortcomings of a primarily cognitive communication style. The hierarchy of communication needs emphasizes trust building, and emotional resonance as prerequisites of effective cognitive discussions, resulting in more effective clinician-patient communication that more fully incorporates cultural humility and better meets the needs of diverse patient populations. Additional research is needed to further develop this strategy and evaluate its impact on patient experience and outcomes.

First-attempt intubation success and complications in patients with COVID-19 undergoing emergency intubation.

Objectives: To evaluate the first-attempt success rates and complications of endotracheal intubation of coronavirus disease 2019 (COVID-19) patients by emergency physicians. Methods: This prospective observational study was conducted from March 24, 2020 through May 28, 2020 at the emergency department (ED) of an urban, academic trauma center. We enrolled patients consecutively admitted to the ED with suspected or confirmed COVID-19 submitted to endotracheal intubation. No patients were excluded. The primary outcome was first-attempt intubation success, defined as successful endotracheal tube placement with the first device passed (endotracheal tube) during the first laryngoscope insertion confirmed with capnography. Secondary outcomes included the following complications: hypotension, hypoxemia, aspiration, and esophageal intubation. Results: A total of 112 patients with confirmed or suspected COVID-19 were enrolled. Median age was 61 years and 61 patients (54%) were men. The primary outcome, first-attempt intubation success, was achieved in 82% of patients. Among the 20 patients who were not intubated on the first attempt, 75% were intubated on the second attempt and 20% on the third attempt; cricothyrotomy was performed in 1 patient. Forty-eight (42%) patients were hypotensive and required norepinephrine immediately post-intubation. Fifty-eight (52%) experienced peri-intubation hypoxemia, and 2 patients (2%) had cardiac arrest. There were no cases of failed intubation resulting in death up to 24 hours after the procedure. Conclusion: Emergency physicians achieve high success rates when intubating COVID19 patients, although complications are frequent. However, these findings should be considered provisional until their generalizability is assessed in their institutions and setting.

Euglycemic Diabetic Ketoacidosis in Pregnancy.

The clinical presentation of diabetic ketoacidosis in pregnancy (DKP) is similar to that observed in nonpregnant women, although reports suggest the presenting blood glucose level may not be as high. It is hypothesized that lower, maternal fasting glucose levels are a result of both the fetus and the placenta consuming glucose. We report the case of a 38-year-old woman gravida 2, para 0, abortion 1 with type 1 diabetes who had euglycemic diabetic ketoacidosis and review the literature on DKP, with a focus on diagnosis, treatment, and monitoring of the mother and fetus.

Interventions of the clinical pharmacist in an Intermediate Care Unit for elderly patients.

OBJECTIVE: To discuss the role of the clinical pharmacist in hospital care of critical elderly patients. METHODS: Critical patients aged 60 years and over admitted by the clinical staff to an Intermediate Care Unit were followed-up for 4 months regarding their drug therapies. Medical prescriptions were reviewed daily on the basis of patients' clinical conditions, with the view to identify opportunities for optimization of drug therapies, contributing to safer prescribing, reduced discomfort and correct and rational use of drugs. RESULTS: A total of 386 prescriptions were reviewed and 212 pharmaceutical interventions performed; 64.3% of prescriptions were classified as accepted with changes, 28.5% not accepted and 7.2% verbally accepted with no changes. Interventions included drug therapy indications, directions for dose adjustment, reduction of the use of potentially inappropriate medications for older patients, prescription adjustments, discontinuing unnecessary drugs, among others. CONCLUSION: The significant number of interventions accepted by the healthcare staff supports the relevance of the clinical pharmacist as a member of the multiprofessional team, especially in care of the elderly.

Interventions of the clinical pharmacist in an Intermediate Care Unit for elderly patients / Intervenções do farmacêutico clínico em uma Unidade de Cuidados Intermediários com foco no paciente idoso

ABSTRACT Objective To discuss the role of the clinical pharmacist in hospital care of critical elderly patients. Methods Critical patients aged 60 years and over admitted by the clinical staff to an Intermediate Care Unit were followed-up for 4 months regarding their drug therapies. Medical prescriptions were reviewed daily on the basis of patients' clinical conditions, with the view to identify opportunities for optimization of drug therapies, contributing to safer prescribing, reduced discomfort and correct and rational use of drugs. Results A total of 386 prescriptions were reviewed and 212 pharmaceutical interventions performed; 64.3% of prescriptions were classified as accepted with changes, 28.5% not accepted and 7.2% verbally accepted with no changes. Interventions included drug therapy indications, directions for dose adjustment, reduction of the use of potentially inappropriate medications for older patients, prescription adjustments, discontinuing unnecessary drugs, among others. Conclusion The significant number of interventions accepted by the healthcare staff supports the relevance of the clinical pharmacist as a member of the multiprofessional team, especially in care of the elderly.

RESUMO Objetivo Discutir o papel do farmacêutico clínico no cuidado hospitalar de pacientes críticos, idosos. Métodos Ao longo do período de 4 meses, foi realizado o acompanhamento farmacoterapêutico de pacientes críticos com 60 anos ou mais, admitidos pela equipe de Clínica Médica em uma Unidade de Cuidados Intermediários. Diariamente, foram realizadas avaliações das prescrições médicas, frente ao quadro clínico, a fim de encontrar oportunidades de otimização da farmacoterapia prescrita, contribuindo para a maior segurança da prescrição, a redução de desconfortos, e o uso correto e racional de medicamentos. Resultados Foram avaliadas 386 prescrições e realizadas 212 intervenções farmacêuticas, sendo 64,3% destas classificadas como aceitas com alteração na prescrição, 28,5% não aceitas e 7,2% aceitas verbalmente, porém sem alteração na prescrição. As intervenções envolviam indicações farmacoterapêuticas, orientações para ajustes de dose, redução do uso de medicamentos potencialmente inapropriados para idosos, ajustes de prescrição, suspensão de medicamentos desnecessários, entre outras. Conclusão O significativo número de intervenções aceitas pela equipe da saúde reforça o papel que o farmacêutico clínico tem a desempenhar na equipe multiprofissional, sobretudo quando direcionados ao cuidado de idosos.

Influência do anticorpo anti-VEGF bevacizumab na inflamação pleural e na pleurodese experimental induzida por talco ou nitrato de prata / Influence of anti-VEGF bevacizumab in pleural inflammation and experimental pleurodesis induced by talc or silver nitrate

Introdução: A pleurodese química é rotineiramente utilizada para o controle de derrames pleurais recidivantes. O fator de crescimento do endotélio vascular (VEGF) é uma citocina produzida em resposta à inflamação pleural induzida por esclerosantes e possui papel essencial na angiogênese e na fibrose pleural. O anticorpo monoclonal bevacizumab bloqueia a ação do VEGF, sendo utilizado no tratamento de algumas neoplasias malignas com o objetivo de inibir a angiogênese e a progressão tumoral. Os efeitos do bevacizumab sobre o processo inflamatório pleural e sobre a pleurodese induzida por talco e nitrato de prata ainda não foram totalmente descritos. Objetivo: Caracterizar a influência do anticorpo monoclonal anti-VEGF, bevacizumab, nas fases precoce e tardia da pleurodese induzida pelo talco ou nitrato de prata. Métodos: Foram estudados 152 coelhos que receberam injeção intrapleural de talco (n=76) ou nitrato de prata (n=76). Metade dos animais em cada grupo recebeu injeção intravenosa de bevacizumab 30 minutos antes do agente esclerosante. Após a injeção intrapleural de talco ou nitrato de prata, 5 animais em cada grupo foram sacrificados em 1, 2, 3, 4, 7, 14 e 28 dias. Um subgrupo de 12 animais recebeu azul de Evans 1 hora antes do sacrifício realizado no terceiro dia, para análise de permeabilidade pleural. Em todos os animais, o líquido pleural obtido foi quantificado, sendo realizadas análises bioquímica, citológica e imunológica. A cavidade pleural foi avaliada macroscopicamente através de escore para quantificação de aderências. Microscopicamente, a pleura visceral foi analisada por escore para o grau de inflamação e fibrose; a densidade vascular foi avaliada por imunohistoquímica (anti fator VIII) e o espessamento pleural e a quantidade de colágeno (fibras colágenas coradas pelo método de picrosirius) mensurados através de um sistema de análise de imagem. Análise Estatística: Os resultados estão expressos em média e erro padrão (SEM)...

Introduction: Chemical pleurodesis is widely used to control recurrent malignant pleural effusion. Vascular endothelial growth factor (VEGF) is produced in response to mesothelial injury by sclerosing intrapleural injection and it is a potent angiogenesis inducer. The monoclonal anti-VEGF bevacizumab inhibits VEGF and has been used in the treatment of cancer to reduce angiogenesis and tumour progression. The effects of VEGF blockage on pleural inflammation and pleurodesis induced by talc and silver nitrate were not completely known. Objective: To describe the effects of monoclonal anti-VEGF bevacizumab in the early and late phase of pleurodesis induced by talc or silver nitrate. Methods: One-hundred and fifty-two rabbits were submitted to intrapleural injection of talc (n = 76) or silver nitrate (n = 76). Half of the animals in each group received intravenous bevacizumab, 30 minutes before the sclerosing agent. In each of the four groups, five animals were sacrificed 1, 2, 3, 4, 7, 14 and 28 days after the intrapleural injection. . A subgroup of twelve animals received intravenous Evans blue one hour prior to sacrifice, to estimate the vascular permeability. The pleural fluid volume was quantified and sent for biochemical, cytological and immunological analysis. Macroscopic pleural adhesions were evaluated using a semiquantitative score. The visceral pleura was submitted to microscopic examination to quantify, by score, inflammation and fibrosis. Anti-factor VII immunostaining was used to evaluate vascular density. Pleural thickness and collagen quantification (sirius red stain was used to identify collagen fibers) were evaluated by an image analysis system. Statistical analysis: Results are expressed as mean and standard error measurement (SEM). Differences between two groups were analyzed using t- test and Mann-Whitney rank sum test and considered statistically significant when p-value was <0.05. Results: Animals pretreated with anti-VEGF...