A prospective comparison between multidisciplinary healthcare providers' clinical examination and a validated pain scale.

Introduction: Unrecognized pain in the Intensive Care Unit (ICU), due to inadequate assessment and therapeutic management, is associated with increased morbidity and mortality. Despite the availability of validated pain monitoring tools, such as the Critical-Care Pain Observational Tool (CPOT), these scales are not commonly used in clinical practice, with healthcare professionals often relying on their clinical impression. Our study aims to determine the agreement between the pain examination performed by ICU professionals and the CPOT. Methods: Prospective cohort study that included critically ill patients and physicians, nurses and physiotherapists from an ICU in Bahia, Brazil. During bedside clinical rounds, the CPOT score was applied to assess the pain of hospitalized patients, and health professionals were interviewed to ascertain their perception of the patient's pain for a maximum of five consecutive days. Correlations were assessed using the Spearman rank tests. Hierarchical cluster analysis was employed to show the results of CPOT score and pain assessment by healthcare professionals at each study time. And the Kappa statistic was calculated to assess the agreement between the CPOT score vs. the pain assessment by healthcare providers. Results: One hundred one patients were included in the study with median age of 74 years (IQR 61.5-83.5), a predominance of women (55.4%) and a median SAPS 3 score of 45 (IQR 39.5-53.0). The correlation between the professional's pain assessment and the CPOT were mostly statistically significant, ranged from negligible to weak, being the highest index obtained in the evaluation of nurses on day 5 (Kappa index = 0.43, p = 0.005). Physician assessments were significant only in day 1. On the presence of pain, the professionals' assessments and CPOT revealed mild to a moderate agreement. Conclusion: Healthcare professional's pain assessment displayed a weak positive correlation with a validated pain scale and poor agreement amongst members of the ICU team, particularly when the pain was felt to be absent. Thus, this study highlights the importance of routine tools for pain assessment in the ICU for all members of multidisciplinary teams.

Ultrasound-Guided Percutaneous Dilational Tracheostomy: A Systematic Review of Randomized Controlled Trials and Meta-Analysis.

INTRODUCTION: Percutaneous dilational tracheostomy (PDT) is a common and increasingly used procedure in the intensive care unit (ICU). It is usually performed with bronchoscopy guidance. Ultrasound has emerged as a useful tool in order to assist PDT, potentially improving its success rate and reducing procedural-related complications. OBJECTIVE: To investigate whether the ultrasound-guided PDT is equivalent or superior to the bronchoscopy-guided or anatomical landmarks-guided PDT with regard to procedural-related and clinical complications. METHODS: A systematic review of randomized clinical trials was conducted comparing an ultrasound-guided PDT to the control groups (either a bronchoscopy-guided PDT or an anatomical landmark-guided PDT) in patients undergoing a PDT in the ICU. The primary outcome was the incidence of major procedural-related and clinical complication rates. The secondary outcome was the incidence of minor complication rates. Random-effect meta-analyzes were used to pool the results. RESULTS: Four studies fulfilled the inclusion criteria and they were analyzed. The studies included 588 participants. There were no differences in the major complication rates between the patients who were assigned to the ultrasound-guided PDT when compared to the control groups (pooled risk ratio [RR]: 0.48; 95% confidence interval [CI]: 0.13-1.71, I2 = 0%). The minor complication rates were not different between the groups, but they had a high heterogeneity (pooled RR: 0.49; 95% CI 0.16-1.50; I2 = 85%). The sensitivity analyzes that only included the randomized controlled trials that used a landmark-guided PDT as the control group showed lower rates of minor complications in the ultrasound-guided PDT group (pooled RR: 0.55; 95% CI: 0.31-0.98, I2 = 0%). CONCLUSION: The ultrasound-guided PDT seems to be safe and it is comparable to the bronchoscopy-guided PDT regarding the major and minor procedural-related or clinical complications. It also seems to reduce the minor complications when compared to the anatomical landmark-guided PDT.

Transfusion requirements after head trauma: a randomized feasibility controlled trial.

BACKGROUND: Anemia is frequent among patients with traumatic brain injury (TBI) and is associated with an increased risk of poor outcome. The optimal hemoglobin concentration to trigger red blood cell (RBC) transfusion in patients with TBI is not clearly defined. METHODS: All eligible consecutive adult patients admitted to the intensive care unit (ICU) with moderate or severe TBI were randomized to a "restrictive" (hemoglobin transfusion threshold of 7 g/dL), or a "liberal" (threshold 9 g/dL) transfusion strategy. The transfusion strategy was continued for up to 14 days or until ICU discharge. The primary outcome was the mean difference in hemoglobin between groups. Secondary outcomes included transfusion requirements, intracranial pressure management, cerebral hemodynamics, length of stay, mortality and 6-month neurological outcome. RESULTS: A total of 44 patients were randomized, 21 patients to the liberal group and 23 to the restrictive group. There were no baseline differences between the groups. The mean hemoglobin concentrations during the 14-day period were 8.4 ± 1.0 and 9.3 ± 1.3 (p < 0.01) in the restrictive and liberal groups, respectively. Fewer RBC units were administered in the restrictive than in the liberal group (35 vs. 66, p = 0.02). There was negative correlation (r = - 0.265, p < 0.01) between hemoglobin concentration and middle cerebral artery flow velocity as evaluated by transcranial Doppler ultrasound and the incidence of post-traumatic vasospasm was significantly lower in the liberal strategy group (4/21, 3% vs. 15/23, 65%; p < 0.01). Hospital mortality was higher in the restrictive than in the liberal group (7/23 vs. 1/21; p = 0.048) and the liberal group tended to have a better neurological status at 6 months (p = 0.06). CONCLUSIONS: The trial reached feasibility criteria. The restrictive group had lower hemoglobin concentrations and received fewer RBC transfusions. Hospital mortality was lower and neurological status at 6 months favored the liberal group. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02203292 . Registered on 29 July 2014.

Influence of seasonal changes in daily activity and annual life cycle of Geotrigona mombuca (Hymenoptera, Apidae) in a Cerrado habitat, São Paulo, Brazil / Influência das mudanças sazonais na atividade diária e no ciclo de vida anual de Geotrigona mombuca (Hymenoptera, Apidae) em hábitat de cerrado, São Paulo, Brasil

The foraging activity of Geotrigona mombuca Smith, 1863 was studied under natural conditions aiming to verify the influence of seasonal changes on daily flight activity and annual cycle of the colony. Daily flight activity was monitored for a year based on the observation and counting of foragers leaving and entering the hive, as well as the kind of material transported and meteorological factors such as day time, temperature and relative humidity. The influence of seasonal changes was evidenced by alterations on daily rhythm of flight activity and by differences on transportation of food resources, building material and garbage. These data indicate that forager behavior is related to daily microclimate conditions and it is synchronized with the requirements of colony annual cycle, which determines an intense pollen collection in the summer. Thus, the recomposition of the intranidal population in spring and summer can be ensured, which is characterized both for a higher intensity of flight activity and increase in garbage and resin transport, as well as the swarming process in the spring. In this way, an action targeting the preservation or management of the species in a natural environment should consider that survival and reproduction of the colony depends greatly on the amount of available pollen in late winter.

A atividade de forrageamento de Geotrigona mombuca Smith, 1863 foi estudada em condições naturais com o objetivo de verificar a influência das mudanças sazonais na atividade diária e no ciclo anual da colônia. A atividade diária de voo foi monitorada, durante um ano, através de contagens de campeiras observadas saindo e entrando na colmeia e o tipo de material transportado, juntamente com os fatores meteorológicos hora do dia, temperatura e umidade relativa do ar. A influência das mudanças sazonais foi constatada pela alteração do ritmo diário da atividade de voo e pelas diferenças no transporte de recursos alimentares, material de construção e de resíduos. Esses dados evidenciam que o comportamento das campeiras está relacionado às condições microclimáticas diárias e sincronizadas com as exigências do ciclo anual da colônia, o qual determina uma intensa coleta de pólen no verão, garantindo a recomposição da população intranidal na primavera e verão, caracterizada tanto pela maior intensidade de atividadede de voo como pelo aumento do transporte de resina e lixo, e enxameagem na primavera. Desse modo, ações direcionadas para a preservação da espécie em ambiente natural ou para o manejo devem considerar que a sobrevivência e reprodução da colônia depende muito da quantidade de pólen disponível no final do inverno.

Influence of seasonal changes in daily activity and annual life cycle of Geotrigona mombuca (Hymenoptera, Apidae) in a Cerrado habitat, São Paulo, Brazil / Influência das mudanças sazonais na atividade diária e no ciclo de vida anual de Geotrigona mombuca (Hymenoptera, Apidae) em hábitat de cerrado, São Paulo, Brasil

The foraging activity of Geotrigona mombuca Smith, 1863 was studied under natural conditions aiming to verify the influence of seasonal changes on daily flight activity and annual cycle of the colony. Daily flight activity was monitored for a year based on the observation and counting of foragers leaving and entering the hive, as well as the kind of material transported and meteorological factors such as day time, temperature and relative humidity. The influence of seasonal changes was evidenced by alterations on daily rhythm of flight activity and by differences on transportation of food resources, building material and garbage. These data indicate that forager behavior is related to daily microclimate conditions and it is synchronized with the requirements of colony annual cycle, which determines an intense pollen collection in the summer. Thus, the recomposition of the intranidal population in spring and summer can be ensured, which is characterized both for a higher intensity of flight activity and increase in garbage and resin transport, as well as the swarming process in the spring. In this way, an action targeting the preservation or management of the species in a natural environment should consider that survival and reproduction of the colony depends greatly on the amount of available pollen in late winter.(AU)

A atividade de forrageamento de Geotrigona mombuca Smith, 1863 foi estudada em condições naturais com o objetivo de verificar a influência das mudanças sazonais na atividade diária e no ciclo anual da colônia. A atividade diária de voo foi monitorada, durante um ano, através de contagens de campeiras observadas saindo e entrando na colmeia e o tipo de material transportado, juntamente com os fatores meteorológicos hora do dia, temperatura e umidade relativa do ar. A influência das mudanças sazonais foi constatada pela alteração do ritmo diário da atividade de voo e pelas diferenças no transporte de recursos alimentares, material de construção e de resíduos. Esses dados evidenciam que o comportamento das campeiras está relacionado às condições microclimáticas diárias e sincronizadas com as exigências do ciclo anual da colônia, o qual determina uma intensa coleta de pólen no verão, garantindo a recomposição da população intranidal na primavera e verão, caracterizada tanto pela maior intensidade de atividadede de voo como pelo aumento do transporte de resina e lixo, e enxameagem na primavera. Desse modo, ações direcionadas para a preservação da espécie em ambiente natural ou para o manejo devem considerar que a sobrevivência e reprodução da colônia depende muito da quantidade de pólen disponível no final do inverno.(AU)