Effects of dexmedetomidine in non-operating room anesthesia in adults: a systematic review with meta-analysis.

BACKGROUND: Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist used for its sedative, analgesic, and anxiolytic effects. Non-Operating Room Anesthesia (NORA) is a modality of anesthesia that can be done under general anesthesia or procedural sedation or/and analgesia. In this particular setting, a level-2 sedation, such as the one provided by DEX, is beneficial. We aimed to study the effects and safety of DEX in the different NORA settings in the adult population. METHODS: A systematic review with meta-analysis of randomized controlled trials was conducted. Interventions using DEX only or DEX associated with other sedative agents, in adults (18 years old or more), were included. Procedures outside the NORA setting and/or without a control group without DEX were excluded. MEDLINE, ClinicalTrials.gov, Scopus, LILACS, and SciELO were searched. The primary outcome was time until full recovery. Secondary outcomes included hemodynamic and respiratory complications and other adverse events, among others. RESULTS: A total of 97 studies were included with a total of 6,706 participants. The meta-analysis demonstrated that DEX had a higher time until full recovery (95% CI = [0.34, 3.13] minutes, a higher incidence of hypotension (OR = 1.95 [1.25, 3.05], p = 0.003, I2 = 39%) and bradycardia (OR = 3.60 [2.29, 5.67], p < 0.00001, I2 = 0%), and a lower incidence of desaturation (OR = 0.40 [0.25, 0.66], p = 0.0003, I² = 60%). CONCLUSION: DEX in NORA procedures in adults was associated with a lower incidence of amnesia and respiratory effects but had a long time to recovery and more hemodynamic complications.

Effects of dexmedetomidine in non-operating room anesthesia in adults: a systematic review with meta-analysis

Abstract Background: Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist used for its sedative, analgesic, and anxiolytic effects. Non-Operating Room Anesthesia (NORA) is a modality of anesthesia that can be done under general anesthesia or procedural sedation or/and analgesia. In this particular setting, a level-2 sedation, such as the one provided by DEX, is beneficial. We aimed to study the effects and safety of DEX in the different NORA settings in the adult population. Methods: A systematic review with meta-analysis of randomized controlled trials was conducted. Interventions using DEX only or DEX associated with other sedative agents, in adults (18 years old or more), were included. Procedures outside the NORA setting and/or without a control group without DEX were excluded. MEDLINE, ClinicalTrials.gov, Scopus, LILACS, and SciELO were searched. The primary outcome was time until full recovery. Secondary outcomes included hemodynamic and respiratory complications and other adverse events, among others. Results: A total of 97 studies were included with a total of 6,706 participants. The meta-analysis demonstrated that DEX had a higher time until full recovery (95% CI = [0.34, 3.13] minutes, a higher incidence of hypotension (OR = 1.95 [1.25, 3.05], p = 0.003, I2 = 39%) and bradycardia (OR = 3.60 [2.29, 5.67], p < 0.00001, I2 = 0%), and a lower incidence of desaturation (OR = 0.40 [0.25, 0.66], p = 0.0003, I2 = 60%). Conclusion: DEX in NORA procedures in adults was associated with a lower incidence of amnesia and respiratory effects but had a long time to recovery and more hemodynamic complications..

Glycaemic control during the COVID-19 pandemic: A catastrophe or a sign of hope for the person with type 1 Diabetes Mellitus?

INTRODUCTION: In a person with type 1 diabetes, any change concerning daily routine may lead to changes in glycaemic control. This study aimed to evaluate the impact of work and lockdown on glycaemic control in adults with type 1 diabetes. MATERIAL AND METHODS: A retrospective cohort was stratified into three activity groups (g1-students/telework/laid-off; g2-unemployed/retired; g3-work without lockdown). Continuous and categorical variations (reductions≥0.4%) in glycated haemoglobin were obtained in 2020 (t3:December/2019-March/2020; t4:April/2020-July/2020) and in homologous periods of 2019. Intragroup comparisons between years and intergroups in the same year were made. Regression models were developed to predict the variation of glycated haemoglobin in 2020. RESULTS: 241 participants were included, with a significant reduction between t4 and t3 (vs. t2 and t1) in g1 (p<0.001) and g2 (p=0.025) and in 2020 in g1 (vs. g2, p<0.001; vs. g3, p<0.001). Only g1 presented superiority in the reduction ≥0.4% in glycated haemoglobin in 2020 (vs. 2019, p<0.001; vs. g2, p<0.001; vs. g3, p<0.001). The insulin regimens were comparable and the development of hypoglycaemia was found to be superimposed between t3 and t4, except for g1, which was higher at t3 (p=0.029). G1 correlated with continuous reductions (vs. g2, p=0.001; vs. g3, p<0.001) and ≥0.4% in glycated haemoglobin in 2020 (vs. g2, OR 3.6, p<0.001; vs. g3, OR 12.7, p<0.001), regardless of the age and duration of type 1 diabetes. CONCLUSIONS: A more stable and better glycaemic control was observed in participants who transitioned from face-to-face work to total lockdown.

Comparison of Blood Pressure Variability between 24 h Ambulatory Monitoring and Office Blood Pressure in Diabetics and Nondiabetic Patients: A Cross-Sectional Study.

Background: Evidence regarding blood pressure (BP) variability (BPV) and its independent association with adverse outcomes has grown. Diabetic patients might have increased BPV, but there is still an evidence gap regarding relation between BPV and type 2 diabetes beyond mean values of BP. Objective: To examine the relationship between 24 h ambulatory BP monitoring (ABPM, short-term variability) and visit-to-visit in-office BPV (OBP, long-term variability), in diabetics (D) and nondiabetics (ND), and to explore BPV relation with estimated glomerular filtration rate (eGFR), and pulse wave velocity (PWV) as indicators of target organ lesion. Materials and Methods: We conducted a single-center cross-sectional study in an outpatient BP unit, including adult patients consecutively admitted from 1999 to 2019. Multivariate was performed to compare BPV between D and ND adjusted for clinical variables. Pearson's correlation was performed to evaluate relation of BPV with eGFR and PWV. Results: A total of 1123 patients with ABPM and OBP measurements were included. Values of eGFR and PWV were worse in D than in ND. Measurements of OBPV did not differ between groups. Of ABPM BPV, the coefficient of variation and standard deviation for daytime systolic BP were higher in D compared to ND, but only in ND did BPV correlated with both eGFR and PWV. Conclusion: We found that diabetes is associated with higher variability of daytime BP than nondiabetics along with worse damage of vascular and renal function. However, in contrast to nondiabetics, in diabetics eGFR and PWV may not be dependent on BP variability, suggesting that other mechanisms might explain more rigorously the greater damage of target organ lesion markers.

Glycaemic control during the COVID-19 pandemic: A catastrophe or a sign of hope for the person with type 1 Diabetes Mellitus?

Introduction: In a person with type 1 diabetes, any change concerning daily routine may lead to changes in glycaemic control. This study aimed to evaluate the impact of work and lockdown on glycaemic control in adults with type 1 diabetes. Material and methods: A retrospective cohort was stratified into three activity groups (g1-students/telework/laid-off; g2-unemployed/retired; g3-work without lockdown). Continuous and categorical variations (reductions ≥ 0.4%) in glycated haemoglobin were obtained in 2020 (t3:December/2019-March/2020; t4:April/2020-July/2020) and in homologous periods of 2019. Intragroup comparisons between years and intergroups in the same year were made. Regression models were developed to predict the variation of glycated haemoglobin in 2020. Results: 241 participants were included, with a significant reduction between t4 and t3 (vs. t2 and t1) in g1 (p < 0.001) and g2 (p = 0.025) and in 2020 in g1 (vs. g2, p < 0.001; vs. g3, p < 0.001). Only g1 presented superiority in the reduction ≥0.4% in glycated haemoglobin in 2020 (vs. 2019, p < 0.001; vs. g2, p < 0.001; vs. g3, p < 0.001). The insulin regimens were comparable and the development of hypoglycaemia was found to be superimposed between t3 and t4, except for g1, which was higher at t3 (p = 0.029). G1 correlated with continuous reductions (vs. g2, p = 0.001; vs. g3, p < 0.001) and ≥0.4% in glycated haemoglobin in 2020 (vs. g2, OR 3.6, p < 0.001; vs. g3, OR 12.7, p < 0.001), regardless of the age and duration of type 1 diabetes. Conclusions: A more stable and better glycaemic control was observed in participants who transitioned from face-to-face work to total lockdown.

Introducción: En una persona con diabetes tipo 1, cualquier cambio en la rutina diaria puede provocar cambios en el control glucémico. Este estudio tuvo como objetivo evaluar el impacto del trabajo y el confinamiento en el control glucémico en adultos con diabetes tipo 1. Material y métodos: Se estratificó una cohorte retrospectiva en tres grupos de actividad (g1-estudiantes/teletrabajo/despido; g2-desempleados/jubilados; g3-trabajo sin encierro). Se obtuvieron variaciones continuas y categóricas (reducciones ≥ 0,4%) en la hemoglobina glucosilada en 2020 (t3: diciembre/2019-marzo/2020; t4: abril/2020-julio/2020) y en períodos homólogos de 2019. Se desarrollaron modelos de regresión para predecir la variación de la hemoglobina glucosilada en 2020. Resultados: Se incluyeron 241 participantes, con una reducción significativa entre t4 y t3 (vs. t2 y t1) en g1 (p < 0,001) y g2 (p = 0,025) y en 2020 en g1 (vs. g2, p < 0,001; vs. g3, p < 0,001). Solo g1 demostró superioridad en la reducción ≥ 0,4% de la hemoglobina glucosilada en 2020 (vs. 2019, p < 0,001; vs. g2, p < 0,001; vs. g3, p < 0,001). Los regímenes de terapia con insulina fueron comparables y el desarrollo de hipoglucemia fue superponible entre t3 y t4, excepto para g1, que fue mayor en t3 (p = 0,029). G1 se correlacionó con reducciones continuas (vs. g2, p = 0,001; vs. g3, p < 0,001) y ≥ 0,4% en la hemoglobina glucosilada en 2020 (vs. g2, odds ratio [OR] 3,6, p < 0,001; vs. g3, OR 12,7, p < 0,001), independientemente de la edad y la duración de la diabetes tipo 1. Conclusiones: Se observó un control glucémico más optimizado a los participantes que pasaron del trabajo presencial al confinamiento total.

Usefulness of Early C-Reactive Protein Kinetics in Response and Prognostic Assessment in Infected Critically Ill Patients: An Observational Retrospective Study.

INTRODUCTION: The ideal biomarker to assess response and prognostic assessment in the infected critically ill patient is still not available. The aims of our study were to analyze the association between early C-reactive protein kinetics and duration and appropriateness of antibiotic therapy and its usefulness in predicting mortality in infected critically ill patients. MATERIAL AND METHODS: We have carried out an observational retrospective study in a cohort of 60 patients with community-acquired pneumonia, aspiration pneumonia and bacteremia at an intensive care unit. We have collected C-reactive protein consecutive serum levels for eight days as well as duration and appropriateness of initial antibiotic therapy. C-reactive protein kinetic groups were defined based on the levels at days 0, 4 and 7. With a follow-up of one year, we have evaluated mortality at different time-points. RESULTS: We have obtained three different C-reactive protein kinetic groups from the sample: fast response, delayed but fast response and delayed and slow response. We did not find statistically significant associations between C-reactive protein kinetics and early (intensive care unit, hospital and 28-days) or late (six months and one year) mortality and antibiotic therapy duration (p > 0.05). Although there were no statistically significant differences between the appropriateness of antibiotic therapy and the defined groups (p = 0.265), no patient with inappropriate antibiotic therapy presented a fast response pattern. DISCUSSION: Several studies suggest the importance of this protein in infection. CONCLUSION: Early C-reactive protein kinetics is not associated with response and prognostic assessment in infected critically ill patients. Nevertheless, a fast response pattern tends to exclude initial inappropriate antibiotic therapy.

Introdução: O biomarcador ideal capaz de avaliar a resposta e prognóstico no doente crítico infetado ainda não está disponível. Os objetivos do nosso estudo foram avaliar a relação da cinética precoce da proteína C-reativa com a duração e apropriação da terapêutica antibiótica e a sua utilidade na predição de mortalidade. Material e Métodos: Realizámos um estudo retrospetivo observacional numa coorte de 60 doentes com pneumonia adquirida na comunidade, pneumonia de aspiração e bacteremia numa unidade de cuidados intensivos. Colhemos níveis séricos de proteína C-reativa durante oito dias e a duração e apropriação da terapêutica antibiótica inicial. Definimos grupos de cinética de proteína C-reativa com base nos níveis dos dias 0, 4 e 7. Durante um ano de seguimento, analisámos a mortalidade em diferentes momentos. Resultados: Da amostra obtivemos três grupos de cinética de proteína C-reativa: resposta rápida, resposta atrasada mas rápida e resposta atrasada e lenta. Não observamos associação estatisticamente significativa entre a cinética da proteína C-reativa com a mortalidade precoce (unidade de cuidados intensivos, hospital e aos 28 dias) ou tardia (seis meses e um ano) e duração da terapêutica antibiótica (p > 0,05). Embora não existam diferenças estatisticamente significativas entre a apropriação da terapêutica antibiótica e os grupos definidos (p = 0,265), nenhum doente com terapêutica antibiótica inapropriada apresentou um padrão de resposta rápida. Discussão: Vários estudos sugerem a importância desta proteína na infeção. Conclusão: A cinética precoce da proteína C-reativa não está associada com a avaliação da resposta e prognóstico no doente crítico infectado. Porém, um padrão de resposta rápida tende a excluir terapêutica antibiótica inicial inapropriada.

Subarachnoid space diameter in chromosomally abnormal fetuses at 11-13 weeks' gestation.

OBJECTIVES: To examine the subarachnoid space diameters in chromosomally abnormal fetuses at 11-13 weeks' gestation. METHODS: Stored three-dimensional (3D) ultrasound volumes of the fetal head at 11-13 weeks' gestation from 407 euploid and 88 chromosomally abnormal fetuses (trisomy 21, n = 40; trisomy 18, n = 19; trisomy 13, n = 7; triploidy, n = 14; Turner syndrome, n = 8) were analyzed. The subarachnoid space diameters, measured in the sagittal and transverse planes of the fetal head, in relation to biparietal diameter (BPD) in each group of aneuploidies was compared to that in euploid fetuses. A total of 20 head volumes were randomly selected and all the measurements were recorded by two different observers to examine the interobserver variability in measurements. RESULTS: In euploid fetuses, the anteroposterior, transverse and sagittal diameters of the subarachnoid space increased with BPD. The median of the observed to expected diameters for BPD were significantly increased in triploidy and trisomy 13 but were not significantly altered in trisomies 21 and 18 or Turner syndrome. In triploidy, the subarachnoid space diameters for BPD were above the 95th centile of euploid fetuses in 92.9% (13 of 14) cases. The intraclass reliability or agreement was excellent for all three subarachnoid space diameters. CONCLUSION: Most fetuses with triploidy at 11-13 weeks' gestation demonstrate increased subarachnoid space diameters.

Ambulatory blood pressure monitoring profiles in a cross-sectional analysis of a large database of normotensive and true or suspected hypertensive patients.

OBJECTIVE: To assess ambulatory blood pressure monitoring (ABPM) circadian patterns and their determinants in a large sample of normotensive and hypertensive patients. METHODS: A total of 26170 individual ABPM recordings from 1995 to 2015 were analyzed. Mean office blood pressure (OBP), 24-hour blood pressure (BP), daytime BP and nocturnal BP were measured. Circadian patterns were classified by nocturnal systolic BP fall as extreme dipper (ED, ≥20%), dipper (D, 10%-19.9%), non-dipper (ND, 0%-9.9%), and reverse dipper (RD, <0%). RESULTS: The population were 52% female, aged 58±15 years, mean body mass index (BMI) 27±5 kg/m2. Using ABPM criteria of normalcy, 22.8% were normotensives (NT), 19.1% were untreated hypertensives, 29.7% were controlled hypertensives and 28.4% were treated but uncontrolled hypertensives. Among NT, 60.7% were white-coat hypertensive. In controlled hypertensives 62.4% had OBP ≥140/90 mmHg. In treated but uncontrolled hypertensives 8.2% had masked uncontrolled hypertension. ABPM values were lower than OBP in all cases. In all subgroups the most common pattern was D (42-50%), followed by ND (35-41%), ED (7-11%) and RD (4-11%). Age and BMI were determinants of attenuation of nocturnal BP fall and ND+RD. The proportion of ND+RD was higher in patients with BMI >30 kg/m2 vs. others (46.5 vs. 42.9%, p<0.01) and in those aged ≥65 vs. <65 years (54.9. vs. 33.1%, p<0.00). Nocturnal BP fall was greater in NT than in hypertensives (11.3±6.7 vs. 9.9±7.9%, p<0.000). CONCLUSIONS: There was a marked discrepancy between office and ABPM values. The rates of control on ABPM were more than double those on OBP. Non-dipping occurred in >43%, including in NT. Age and BMI predicted non-dipping.

Complications of central lines in neonates admitted to a level III Neonatal Intensive Care Unit.

OBJECTIVE: To investigate the incidence and risk factors for central line related complications in neonates. METHODS: A retrospective cohort study of infants who underwent central line (CL) placement, from 1 July 2014 to 31 June 2016, was conducted in Neonatal Intensive Care Unit of Centro Hospitalar de São João. Infants hospitalized more than 2 d and CLs placed for more than 24 h were included. Patients' demographic characteristics, hospital data, and information on CLs were collected. Indwelling complications were compared between infant groups and types of CL inserted. RESULTS: A total of 400 CLs were inserted in 240 infants with a CL utilization ratio of 0.64. Overall CL complication rate was 29.6 per 1000 catheter days. Of all complications, central line-associated bloodstream infection had the highest incidence (12.4 per 1000 catheter days). Infiltration was the most reported mechanical complication. Non-umbilical catheters showed a significantly higher incidence of complications than umbilical ones. Low gestational age, low birth weight, prolonged catheter stay, long duration of total parenteral nutrition, and peripherally inserted central catheter placement were associated with a higher risk of indwelling complication. CONCLUSIONS: The implementation of measures to prevent catheter-related complications must be a priority in care of vulnerable neonates.

Periconceptional CMV infection prevention in Portugal: population subgroup study in a tertiary perinatal care center.

Currently in Portugal, universal screening of pregnant women for Cytomegalovirus (CMV) infection is not performed. However, it is recommended to screen all women attending preconception care. We aimed to assess women's attendance to preconception care and if their serologic status regarding CMV was known and/or investigated in that consultation. In this cross-sectional study, we interviewed 240 women admitted to the obstetrical ward of a hospital in the Metropolitan Area of Porto (Portugal) about their adherence to preconception care and collected data regarding their CMV serologic status and its investigation. We found that 71.3% of the women who attended preconception care were not screened for CMV infection. Among primigravida, the screening rate was only of 30.4% (upper limit of CI 95%: 44.8%). There were no statistically significant differences between the private and public sectors of healthcare. We observed attendance to preconception care is high (73.1%). For the population subgroup of the metropolitan area of Porto, attendance to preconception care is at least 66%, with a 95% confidence level. Portuguese guidelines stating a woman's serologic status regarding CMV should be investigated in preconception care are not properly implemented. This suggests guidelines should assure the screening of previously non-screened women during pregnancy.

Association between ambulatory blood pressure values and central aortic pressure in a large population of normotensive and hypertensive patients.

OBJECTIVE: Our aim was to examine the association of ambulatory blood pressure monitoring (ABPM) and central blood pressure (CBP) data in a large set of normotensive and hypertensive patients and its relation with pulse wave velocity (PWV). PATIENTS AND METHODS: This cross-sectional study was carried out in a single centre and included 2864 individuals who carried out an ABPM, measurement of CBP from the aortic waveform (SphygmoCor) and carotid-femoral PWV (Complior). RESULTS: In our study, 26.6% of the normotensive individuals and 32.5% of controlled hypertensive patients had abnormal values of at least one or of both ABPM and CBP values, compared with 96.6% of uncontrolled hypertensive patients. In the overall population, normal ABPM and CBP occurred in 25.3% (group 1), abnormal ABPM and CBP occurred in 44.4% (group 4), abnormal ABPM and normal CBP occurred in 10.5% (group 3) and normal ABPM and abnormal CBP occurred in 19.8% (group 2). PWV was significantly superior in group 4 versus group 3; group 4 versus group 1 and group 3 versus group 2 and group 2 versus group 1 (Mann-Whitney U-test; P<0.001). CONCLUSION: At least 26-32% of patients classified as normotensive or controlled hypertensive patients have abnormal ABPM or CBP associated with target organ damages. When abnormal values of ABPM and CBP coexist, target organ damage (aortic stiffness) is greater than that occurring when only one abnormal ABPM or CBP is present in the absence of the other. Isolated central hypertension entails greater organ damage than both normal ABPM and CBP. These patients may be at higher risk of further target organ damage because of unawareness of their central hypertension.

Probiotics for the control of obesity - Its effect on weight change.

BACKGROUND: Obesity is a growing epidemic worldwide. Evidence so far demonstrates that the bacteria that are commonly found in the human gastrointestinal tract affect nutrient acquisition and energy regulation. This suggests that an important role is played by gut microbiota in the development of obesity. OBJECTIVES: Our main goal was to assess if a probiotic diet leads to a significant difference in weight change in non-obese and obese people, and in experimental models. METHODS: Search was undertaken in PubMed, Scopus, ISI Web of knowledge, Cochrane Central Register of Controlled Trials, Google scholar, meta-Register of Controlled Trials, ClinicalTrials.gov and by scanning reference lists of articles, without publication date imposed, for randomised clinical trials studying the administration of probiotics to obese or overweight patients and experimental studies in experimental models and healthy humans. Search terms included probiotics, obesity, weight, BMI, weight gain, weight loss, weight change, probiotic diet and probiotic therapy. In an unblended standardized manner, 2 reviewers analysed the searched studies, using the defined inclusion and exclusion criteria, and performed extraction of data, in an independent way, using predefined data fields. RESULTS: We've identified, through searching databases specified in methods, 269 records. A total of 4 clinical trials and 14 experimental studies were included in the systematic review. Among the 4 randomized clinical trials only one showed statistically significant results. L. rhamnosus CGMCC 1.3724 was efficient in reducing weight in females, but not in males - Mean weight loss 12 week/24 week (kg): Males-probiotic: 4/5.4; Males-placebo: 3.05/4.43; Females-probiotic: 4.4/5.2; Females- placebo: 2.6/2.5 (P<0.05 only on females). CONCLUSIONS: In our systematic review, we found that probiotic effect in body weight is specie and strain specific. L. gasseri BNR17, reduced the weight gain compared to controls; L. gasseri L66-5 promoted weight gain, L. rhamnosus GGMCC is the only one that had a positive effect in weight loss in humans. Probiotic effect in body weight was species and strain specific. On the other hand L. plantarum LG42, L. gasseri SBT2055 and L. plantarum co-therapy with KY103 and L. curvatus HY7601 had an anti-obesity effect in animal models.