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Background: In refractory respiratory failure (RF), extracorporeal membrane oxygenation (ECMO) is a salvage therapy that seeks to reduce lung injury induced by mechanical ventilation. The parameters of optimal mechanical ventilation in children during ECMO are not known. Pulmonary ventilatory management during this therapy may impact mortality. The objective of this study was to evaluate the association between ventilatory parameters in children during ECMO therapy and in-hospital mortality. Methods: A systematic search of PubMed/MEDLINE, Embase, Cochrane, and Google Scholar from January 2013 until May 2022 (PROSPERO 450744), including studies in children with ECMO-supported RF assessing mechanical ventilation parameters, was conducted. Risk of bias was assessed using the Newcastle-Ottawa scale; heterogeneity, with absence <25% and high >75%, was assessed using I2. Sensitivity and subgroup analyses using the Mantel-Haenszel random-effects model were performed to explore the impact of methodological quality on effect size. Results: Six studies were included. The median age was 3.4 years (IQR: 3.2-4.2). Survival in the 28-day studies was 69%. Mechanical ventilation parameters associated with higher mortality were a very low tidal volume ventilation (<4â ml/kg; OR: 4.70; 95% CI: 2.91-7.59; p < 0.01; I2: 38%), high plateau pressure (mean Dif: -0.70 95% CI: -0.18, -0.22; p < 0.01), and high driving pressure (mean Dif: -0.96 95% CI: -1.83, -0.09: p = 0.03). The inspired fraction of oxygen (p = 0.09) and end-expiratory pressure (p = 0.69) were not associated with higher mortality. Patients who survived had less multiple organ failure (p < 0.01). Conclusion: The mechanical ventilation variables associated with higher mortality in children with ECMO-supported respiratory failure are high plateau pressures, high driving pressure and very low tidal volume ventilation. No association between mortality and other parameters of the mechanical ventilator, such as the inspired fraction of oxygen or end-expiratory pressure, was found. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023450744, PROSPERO 2023 (CRD42023450744).
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BACKGROUND EPTS (Estimated Post-Transplant Survival), KDRI (Kidney Donor Risk Index), and KDPI (Kidney Donor Profile Index) were developed aiming to ameliorate donor-recipient longevity matching in kidney transplants. They are based on a prediction model made using the United States population; evidence of their use outside EEUU remains limited. The aim of this study was to describe the quality of deceased-donor kidneys and to determine recipient and graft survival, glomerular filtration rate, and incidence of delayed graft function in renal transplantation according to these indices in Cali, Colombia. MATERIAL AND METHODS In this historical cohort study, Kaplan-Meier method was used to analyze survival of recipient and graft according to the values of the indices categorized by quintiles. Glomerular filtration rate and incidence of delayed graft function were also analyzed according to KDRI and KDPI. RESULTS We included 380 patients. Medians of EPTS, KDRI, and KDPI were 24% (IQR 9-60), 0.8 (IQR 0.71-0.99), and 27% (IQR 13-49), respectively. Two-year survival was 97.8% in recipients with EPTS ≤20% and it decreased with higher values of the index. Recipient and graft survival were lower for all periods when donors had KDPI >80%. Incidence of delayed graft function was higher in patients whose donors had KDPI ≥60% (44% vs 21%). Glomerular filtration rate decreased with the highest values of KDPI for all periods. CONCLUSIONS Our study represents the initial evaluation of the usefulness of these indices in Colombia. Our results suggest that KDRI, KDPI, and EPTS may serve as valuable tools for kidney allocation in our setting. Further research with larger sample sizes is necessary to validate these indices in our population.
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Transplante de Rim , Humanos , Estados Unidos , Transplante de Rim/efeitos adversos , Sobrevivência de Enxerto , Função Retardada do Enxerto/etiologia , Estudos de Coortes , Colômbia , Doadores de Tecidos , Rim , Estudos RetrospectivosRESUMO
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in patients with cancer. On the basis of results from randomized controlled trials, direct oral anticoagulants (DOACs) are now recommended for the treatment of cancer-associated VTE. The decision to use a DOAC requires consideration of bleeding risk, particularly in patients with gastrointestinal (GI) malignancies, the cost-benefit and convenience of oral therapy, and patient preference. While efficacy with apixaban, edoxaban, and rivaroxaban versus dalteparin has been consistent in the treatment of cancer-associated VTE, heterogeneity is evident with respect to major GI bleeding, with an increased risk with edoxaban and rivaroxaban but not apixaban. Although cost and accessibility vary in different countries of Latin America, DOACs should be considered for the long-term treatment of cancer-associated VTE in all patients who are likely to benefit. Apixaban may be the preferred DOAC in patients with GI malignancies and LMWH may be preferred for patients with upper or unresected lower GI tumors. Vitamin K antagonists should only be used for anticoagulation when DOACs and low molecular weight heparin are inaccessible or unsuitable.
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Anticoagulantes/administração & dosagem , Neoplasias/complicações , Tromboembolia Venosa/tratamento farmacológico , Administração Oral , Coagulação Sanguínea/efeitos dos fármacos , Humanos , Incidência , América Latina/epidemiologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologiaRESUMO
OBJECTIVES: To determine which multicenter randomized controlled trials in critically ill patients have shown that the study intervention was associated with a statistically significant reduction in mortality. Our analysis provides an update to a report published 10 years ago. DATA SOURCES: MEDLINE database and PubMed interface from inception until April 30, 2019. STUDY SELECTION: All adult multicenter randomized controlled trials that evaluated the effects of any intervention or monitoring system in critically ill patients and reported mortality as a primary or secondary outcome were included. DATA EXTRACTION: Numbers of centers and patients, type of intervention, reported mortality outcome, and rate and level of significance were extracted into predefined tables. Included randomized controlled trials were classified as reporting reduced, increased, or no effect of the intervention on mortality. Methodologic quality of trials was evaluated using the updated Consolidated Standards of Reporting Trials statement. DATA SYNTHESIS: A total of 212 trials met the inclusion criteria: 27 (13%) reported a significant reduction in mortality, 16 (7%) an increase in mortality, and 170 (80%) no difference in mortality (one study was reported in 2 groups). Of the 27 trials reporting reduced mortality, six had assessed interventions likely to decrease ventilator-induced lung injury, including low tidal volume, prone position, and neuromuscular blockers, demonstrating the negative effects of mechanical ventilation strategies or improved process of care rather than positive effects of new therapies. Seven of the 27 trials reported beneficial effects of noninvasive ventilation. Results from some positive randomized controlled trials, for example, studies of recombinant activated protein C, talactoferrin, interleukin-1 receptor antagonist in sepsis, and muscle relaxants in severe acute respiratory distress syndrome were not replicated in subsequent randomized controlled trials. Other interventions, for example, gastric tonometry, have been abandoned. CONCLUSIONS: A systematic literature search provided no conclusive evidence of any pharmacologic intervention that has consistently reduced mortality in critically ill patients. Strategies associated with improved or noninvasive mechanical ventilation were associated with reduced mortality.
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Cuidados Críticos , Estado Terminal/mortalidade , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , HumanosRESUMO
Resumen Desde hace algunos años se ha sugerido que los pacientes con síndrome de apnea-hipopnea obstructiva del sueño sin tratamiento tienen una mayor probabilidad de cáncer sólido y de mortalidad por cáncer, sin embargo hay dudas frente al tema. Por esta razón, en este artículo se describen, por un lado, los estudios más importantes al respecto y, por el otro, la fisiopatología propuesta por los investigadores que plantean esta asociación donde la hipoxia, el daño oxidativo del DNA, la disfunción endotelial y la disrupción de la arquitectura del sueño juegan un papel fundamental, además de otras consideraciones interesantes.
Abstract For some years, it has been suggested that patients with untreated obstructive sleep apnea-hypopnea syndrome are more likely to have solid cancer and increased cancer mortality, although some doubt on the issue has arisen. In consequence, this article describes, on the one hand, the most important studies on the topic and, on the other, the pathophysiology proposed by researchers, who formulate an association in which hypoxia, DNA oxidative damage, endothelial dysfunction and the disruption of the dream architecture play a fundamental role, in addition to other interesting considerations.
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Sr. Editor: En enero del anoË en curso, la Extracorporeal life support organization (ELSO), la más grande entidad que recoge y divulga información acerca de soporte vital extracorpóreo en el mundo, emitió el último reporte de estadísticas llevadas a cabo desde 1990 hasta 2014, en el que se observa una tendencia clara: el aumento del número de pacientes y de centros en los cuales se realiza oxigenación por membrana extracorpórea (ECMO) desde el inicio del registro, llegándose a 251 centros inscritos y 5.037 pacientes con una supervivencia general del 71%1 . El 2014 fue el primer anoË en el que se reportó una disminución en el número de pacientes en comparación con el 2013 (5.626 casos). Una de las razones que pueden explicar este comportamiento particular es la posible estabilización de la cantidad de pacientes en una cifra cercana a este número ya que se calcula que debe existir un centro de ECMO por cada 2 a 3 millones de habitantes, y cada uno de estos centros debe llevar en promedio 12 pacientes anuales, datos que, aproximadamente, equivalen a la población total del número de países en los cuales está disponible esta terapia. Tampoco se debe obviar un importante subregistro de pacientes de centros no inscritos en la ELSO, dentro de los que se cuentan casi todos los centros de Colombia. Es posible que muchos centros no registrados estén utilizando cada vez más esta terapia, pero que este incremento no se refleje en las estadísticas del ente verificador.
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Oxigenação por Membrana Extracorpórea , SobrevivênciaRESUMO
INTRODUCTION: Palliative sedation (PS) is the subject of ethical and legal debates worldwide. Statistics of its utilization are available in developed countries; however, in Latin America, these data are scarcely known. The purpose of this research was to determine the practices and attitudes of palliativists in Latin America towards PS. MATERIALS AND METHODS: Data was collected during the Latin American Congress on Palliative Care in Isla Margarita, Venezuela. A total of 89 professionals participated in this survey. RESULTS: It was found that the use of PS was positively associated with being a physician and being members of a palliative care (PC) group. On the other hand, it was found that being a psychologist and identifying barriers toward PS limited its utilization. DISCUSSION: The findings of this study support the need to establish clinical guidelines for its utilization and to educate other specialists on end-of-life care approaches, and the need to develop PC programs in acute care hospitals in Latin America.
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Atitude do Pessoal de Saúde , Hipnóticos e Sedativos/uso terapêutico , Cuidados Paliativos/ética , Prática Profissional/ética , Assistência Terminal/ética , Adulto , Competência Clínica , Estudos Transversais , Demografia , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , América Latina , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/psicologia , Cuidados Paliativos/estatística & dados numéricos , Relações Médico-Paciente , Assistência Terminal/psicologiaRESUMO
Introducción: la restauración de la función del orbicular de los párpados en un paciente con parálisis facial periférica, representa un reto para el oftalmólogo. Las medidas terapéuticas en general se consideran paliativas y los procedimientos quirúrgicos resultan con frecuencia en correcciones parciales. El presente estudio experimental pretendió demostrar la posibilidad de simular un parpadeo normal utilizando estimulación eléctrica en perros con parálisis facial periférica. Métodos: ocho perros con parálisis facial inducida quirúrgicamente recibieron estimulación eléctrica directa por medio de electrodos implantados en el espesor del orbicular de los párpados. Resultados: se logró inducir un cierre palpebral considerado como satisfactorio en todos los especímenes utilizados. Conclusiones: es posible inducir un parpadeo similar al normal en perros con parálisis facial periférica utilizando estimulación eléctrica directa. Se discuten las opciones para una potencial adaptación de un sistema similar en humanos