Eficacia y seguridad de la mascarilla laríngea Protector (R) en procedimientos respiratorios invasivos / Efficacy and safety of the Protector (R) laryngeal mask in invasive respiratory procedures

Objetivos: Las pruebas respiratorias invasivas pueden ser realizadas bajo sedación profunda o preferentemente bajo anestesia general para facilitar su rea- lización y evitar complicaciones. Dichas pruebas requieren del manejo compartido de la vía aérea junto al neumólogo, por lo que tubos endotraqueales de gran calibre será necesarios para garantizar la ventilación. Una alternativa a la intubación sería la colocación de una mascarilla laríngea (ML). Pocos estudios recogen la realización de dichas pruebas con ML y no existe ningún estudio en el que se haya realizado con la ML Protector®. Esta ML presenta un gran canal calibre interno y la suficiente flexibilidad para poder realizarla reduciendo los riesgos de intubación. El objetivo de este estudio es demostrar la seguridad de la mascarilla laríngea Protector® para la realización de pruebas respiratorias invasivas.Metodología: Se reclutaron 55 pacientes consecutivos que fueron sometidos a pruebas respiratorias invasivas con la mascarilla laríngea Protector®. Resultados: La tasa de éxito con la ML Protector® ha sido del 92 % sin presentar complicaciones. La ventilación es garantizada con menores presiones pico que con un tubo endotraqueal, ningún paciente ha referido dolor de garganta y todos los pacientes fueron dados de alta como máximo a las 4 horas tras el procedimiento.Conclusiones: La realización de pruebas respiratorias invasivas con ML Protector® es seguro reduciendo las complicaciones asociadas a intubaciones con tubos de gran calibre y reduciendo las presiones para asegurar su ventilación. (AU)

Objective: Invasive respiratory tests can be performed under deep sedation or preferably under general anesthesia to facilitate their performance and avoid complications. These procedures require shared management of the airway with the pulmonologist, so large-caliber endotracheal tubes will be necessary to guarantee ventilation. An alternative to intubation would be the placement of a laryngeal mask. Few studies record the performance of such tests with LM and there are no studies in which it has been performed with LM Protector®. This LM presents a large internal caliber canal and sufficient flexibility to perform it, reducing the risks of intubation. The objective of this study is to demonstrate the safety of the Protector® laryngeal mask for invasive respiratory procedures. Method: Fifty-five consecutive patients who underwent invasive respiratory procedures with the Protector® laryngeal mask were recruited.Results: The success rate with the LM Protector has been 92 % without complications. Ventilation is guaranteed with lower peak pressures, no patient has reported a sore throat and all patients were discharged at most 4 hours after the procedure.Conclusions: Performing ventilatory respiratory procedures with LM Protector® is safe, reducing the complications associated with large-caliber tubes intubation. (AU)

COMPASS-CP: An Electronic Application to Capture Patient-Reported Outcomes to Develop Actionable Stroke and Transient Ischemic Attack Care Plans.

Background Patient-reported outcomes (PROs) are clinical tools that measure patients' goals of care and assess patient-reported physical, mental, and social well-being. Despite their value in advancing patient-centered care, routine use of PROs in stroke management has lagged. As part of the pragmatic COMPASS (Comprehensive Post-Acute Stroke Services) trial, we developed COMPASS-Care Plan (CP), a clinician-facing application that captures and analyzes PROs for stroke and transient ischemic attack patients discharged home and immediately generates individualized electronic CP. In this report, we (1) present our methods for developing and implementing COMPASS-CP PROs, (2) provide examples of CP generated from COMPASS-CP, (3) describe key functional, social, and behavioral determinants of health captured by COMPASS-CP, and (4) report on clinician experience with using COMPASS-CP in routine clinical practice for care planning and engagement of stroke and transient ischemic attack patients discharged home. Methods and Results We report on the first 871 patients enrolled in 20 North Carolina hospitals randomized to the intervention arm of COMPASS between July 2016 and February 2018; these patients completed a COMPASS follow-up visit within 14 days of hospital discharge. We also report user satisfaction results from 56 clinicians who used COMPASS-CP during these visits. COMPASS-CP identified more cognitive and depression deficits than physical deficits. Within 14-day posthospitalization, less than half of patients could list the major risk factors for stroke, 36% did not recognize blood pressure as a stroke risk factor, and 19% of patients were nonadherent with prescribed medications. Three-fourths of clinicians reported that COMPASS-CP identifies important factors impacting patients' recovery that they otherwise may have missed, and two-thirds were highly satisfied with COMPASS-CP. Conclusions The COMPASS-CP application meets an immediate need to incorporate PROs into the clinical workflow to develop patient-centered CP for stroke patients and has high user satisfaction. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT02588664.

Blood utilization and mortality in victims of gun violence.

BACKGROUND: Blood transfusion can be lifesaving for patients with hemorrhage; however, transfusion requirements for victims of gun violence are poorly understood. STUDY DESIGN AND METHODS: In an urban, Level 1 trauma center, 23,422 trauma patients were analyzed in a retrospective cohort study. Patients with gunshot wounds (GSWs) (n = 2,672; 11.4% of trauma patients) were compared to those with non-GSW traumatic injuries from 2005 to 2017, to assess blood utilization. RESULTS: The GSW cohort was approximately five times more likely to require transfusion (538 of 2672 [20.1%] vs. 798 of 20,750 [3.9%]; p < 0.0001), and the number of blood component units transfused per patient was approximately 10 times greater (3.3 ± 13.5 vs. 0.31 ± 3.8 units/patient; p < 0.0001), compared to the non-GSW cohort. The risk-adjusted likelihood of requiring high-dose transfusion was greater in the GSW cohort (odds ratio, 2.38; 95% confidence interval, 1.14-5.80), and requirements were increased for all four blood components (red blood cells, platelets, plasma, and cryoprecipitate). Patients with GSWs had approximately 14 times greater overall mortality (653 of 2672 [24.4%] vs. 352 of 20,750 [1.7%]; p < 0.0001]. Compared to non-GSW penetrating injuries (e.g., stab wounds), those with GSWs had approximately four times higher transfusion requirements (3.3 ± 13.5 vs. 0.80 ± 3.8 units/patient; p < 0.0001), and approximately eight times greater overall mortality (653 of 2672 [24.4%] vs. 28 of 956 [2.9%]; p < 0.0001). CONCLUSIONS: Compared to other traumatic injuries, GSW injuries are associated with substantially greater blood utilization and mortality. Trauma centers treating GSW injuries should have ready access to all blood components and ability to implement massive transfusions.

[Substance related disorder in emergency services: Which attitudes?] / Autoévaluation des attitudes soignantes aux urgences face aux conduites addictives. Étude exploratoire.

INTRODUCTION: Substance related disorders are more prevalent in emergency services than in the general population, about 20% of individuals in emergency care test positive for alcohol. Emergency services are strategic places to identify alcohol misuse. Attitudes to individuals presenting substance related disorders are important in developing therapeutic relationships and applying interventions. OBJECTIVE: This study explores the attitudes of an emergency staff to these individuals across a range of roles, and evolution in face of an addictology care improvement. METHOD: Data were gathered from an emergency service sample from the emergency department of a general hospital in Morlaix (France). We used a short questionnaire, adapted from previous similar French studies. RESULTS: Twenty-five persons answered the first questionnaire and 18 the second. A self-administrated attitudes questionnaire showed its interest in our study and helped us to identify attitudes and to initiate a reflection on behaviours in emergency care. Moreover, it helped to change attitudes towards individuals presenting substance related disorders. The daily setting of an addictive disorders specialized unit in emergency changed the point of view on addictive disorders of both physicians and nurses. We showed differences in addictive related disorders prevalence perception among patients attending emergency care between the two evaluations. But we also showed that physicians and nurses stressed that it was more difficult to ask patients in emergency care on the second evaluation, after and despite a daily addictive disorders specialized setting. We showed several limits in emergency staff care relationship with patients with substance related disorders. They identified difficulties to talk about addictive disorders, especially in younger and older patients. Regarding literature, we discuss our study limits and different ways of improving addictology care in emergency services.

A mathematical model applied for assisting the estimation of PMI in a case of forensic importance. First record of Conicera similis (Diptera: Phoridae) in a corpse.

We present a forensic case associated with skeletonized human remains found inside a cistern in a coastal town located in the eastern Iberian Peninsula (Valencian Regional Government, Spain). In order to analyse the particular environmental conditions that occurred during oviposition and development of the collected insects, estimated temperatures at the crime scene were calculated by a predictive mathematical model. This model analyses the correlation between the variability of the internal temperature depending on the variability of the external ones. The amplitude of the temperature oscillations inside the tank and the containment of the enclosure is reduced by the presence of water. Such variation occurred within about 2h due to the time required for heat exchange. The differential equations employed to model differences between outdoor and indoor temperatures were an essential tool which let us estimate the post-mortem interval (PMI) that was carried out by the study of the insect succession and the development time of the collected Diptera specimens under the adjusted temperatures. The presence of live larvae and pupae of Sarcophagidae and empty pupae of Calliphoridae, Sarcophagidae, Fanniidae, Muscidae, Phoridae and Piophilidae and the decomposition stage suggested the possibility that the remains were in the tank at least a year. We highlight the absence of Calliphora and Lucilia spp., and the first occurrence of the phorid Conicera similis in a human cadaver among the entomological evidence.

Kinetic characterization of a glycoside hydrolase family 44 xyloglucanase/endoglucanase from Ruminococcus flavefaciens FD-1.

Two forms of Ruminococcus flavefaciens FD-1 endoglucanase B, a member of glycoside hydrolase family 44, one with only a catalytic domain and the other with a catalytic domain and a carbohydrate binding domain (CBM), were produced. Both forms hydrolyzed cellotetraose, cellopentaose, cellohexaose, carboxymethylcellulose (CMC), birchwood and larchwood xylan, xyloglucan, lichenan, and Avicel but not cellobiose, cellotriose, mannan, or pullulan. Addition of the CBM increased catalytic efficiencies on both CMC and birchwood xylan but not on xyloglucan, and it decreased rates of cellopentaose and cellohexaose hydrolysis. Catalytic efficiencies were much higher on xyloglucan than on other polysaccharides. Hydrolysis rates increased with increasing cellooligosaccharide chain length. Cellotetraose hydrolysis yielded only cellotriose and glucose. Hydrolysis of cellopentaose gave large amounts of cellotetraose and glucose, somewhat more of the former than of the latter, and much smaller amounts of cellobiose and cellotriose. Cellohexaose hydrolysis yielded much more cellotetraose than cellobiose and small amounts of glucose and cellotriose, along with a low and transient amount of cellopentaose.

Preemptive ropivacaine local anaesthetic infiltration versus postoperative ropivacaine wound infiltration in mastectomy: postoperative pain and drain outputs.

OBJECTIVE: The aim of this study was to investigate if preemptive local infiltration (PLA) with ropivacaine could improve postoperative pain and determine its effect on drain output postmastectomy with axillary dissection. METHODS: This was a prospective, randomized trial comprising 30 women allocated to two groups: one to receive postoperative wound infiltration (POW) of 20 mL of 0.2% (40 mg) ropivacaine (Naropin) versus PLA with 20 mL of 0.2% ropivacaine (Naropin) diluted with 80 mL of 0.9% saline, total volume 100 mL. A visual analogue scale (0-100 mm) and angle of shoulder abduction were used for evaluation of pain. Postoperatively, all patients received oral ibuprofen 400 mg tds. RESULTS: There was no significant difference in postoperative pain for the first 3 days between the two groups. There were wider shoulder abduction angles in the 1st and 3rd postoperative days in the PLA group, but this was not significant. Operative time was significantly shorter in the PLA group than in the POW group (69.34+/-59.37 minutes vs. 109.67+/-26.96 minutes; p=0.02). The axillary drain was removed earlier in the preemptive group, 5.4+/-1.55 days versus 6.8+/-2.04 days in the postoperative group (p=0.04). CONCLUSION: We found no difference in postoperative pain between preemptive tumescent ropivacaine infiltration and postoperative ropivacaine wound infiltration.

Pudendal thigh flap for repair of rectovaginal fistula.

The pudendal thigh flap or the Singapore flap is a versatile flap that can be used in the repair of recto-vaginal fistulae. Apart from the potential problem of hair growth, this neurovascular flap proves to be surprisingly simple in technique, robust and has a high potential for normal or near-normal function.

Cuando la retirada de la ventilación mecánica es dificultosa en la UCIP: caso clínico / When the weaning from mechanical ventilation is difficult in the UCIP: report of a case

Paciente de 22 meses que presenta como complicación postquirúrgica, de cirugía torácica, sección del nervio frénico derecho con la consiguiente parálisis hemidiafragmática. Se comentan algunos aspectos fisiopatológicos de tal afección y se discuten las estrategias ante un weaning dificultoso (AU)

Cuando la retirada de la ventilación mecánica es dificultosa en la UCIP: caso clínico / When the weaning from mechanical ventilation is difficult in the UCIP: report of a case

Paciente de 22 meses que presenta como complicación postquirúrgica, de cirugía torácica, sección del nervio frénico derecho con la consiguiente parálisis hemidiafragmática. Se comentan algunos aspectos fisiopatológicos de tal afección y se discuten las estrategias ante un weaning dificultoso

Chemotherapy-induced emesis: management of early and delayed emesis in milder emetogenic regimens.

The objective of the present study was to examine the problem of the control of nausea and vomiting induced by non-cisplatin containing cyclophosphamide-based chemotherapy regimens in breast cancer patients. This was randomized, double-blind, parallel-group and placebo-controlled study comparing the efficacy of three antiemetic therapeutic regimens (ondansetron for 3 days, ondasetron plus metoclopramide, and ondansetron given in a single dose) in breast cancer patients receiving cyclophosphamide-based chemotherapy regimens on an outpatient basis. Both the primary and the secondary efficacy were measured. The primary efficacy variable was the number of emetic episodes (considering early and delayed emesis). The secondary efficacy variable measured was the quality of life. Two-by-two tables using the chi-square test and relative-risk concept were elaborated for statistical analysis. There was no difference between high-dose ondansetron and ondansetron plus metoclopramide among patients given CMF (cyclophosphamide, methotrexate, 5-fluorouracil). The single-dose ondansetron regimen showed the worst results. In patients given an FEC regimen (cyclophosphamide, epirubicin, 5-fluorouracil) the antiemetic efficacy was best for the high-dose ondansetron regimen, followed by the ondansetron plus metoclopramide regimen, and was worst for single-dose ondansetron administration. Despite the use of different antiemetic schedules, nausea and emesis are significant problems in patients receiving cyclophosphamide-based chemotherapy. Their adequate control should be the aim of any antiemetic approach.