Perioperative management in thoracic surgery Muñoz de Cabo, C; Hermoso Alarza, F; Cossio Rodriguez, A M ...
Medicina intensiva,
04/2020, Letnik:
44, Številka:
3
Journal Article
Recenzirano
Thoracic surgery has undergone significant advances in recent years related to anesthetic and surgical techniques and the prevention and management of complications related to the procedure. This has ...allowed improvements in patient clinical outcomes in surgeries of this kind. Despite the above, thoracic surgery, especially related to pulmonary resection, is not without risk, and is associated to considerable morbidity and mortality. Fast track or enhanced recovery after anesthesia protocols, minimally invasive surgery, and intraoperative anesthetic management improve the prognosis and safety of thoracic surgery. Patients in the postoperative period of major thoracic surgery require intensive surveillance, especially the first 24-72hours after surgery. Admission to the ICU is especially recommended in those patients with comorbidities, a reduced cardiopulmonary reserve, extensive lung resections, and those requiring support due to life-threatening organ failure. During the postoperative period, intensive cardiorespiratory monitoring, proper management of thoracic drainage, aggressive pain control (multimodal analgesia and regional anesthetic techniques), nausea and multimodal rehabilitation are key elements for avoiding adverse events. Medical complications include respiratory failure, arrhythmias, respiratory infections, atelectasis and thromboembolic lung disease. The most frequent surgical complications are hemothorax, chylothorax, bronchopleural fistula and prolonged air leakage. The multidisciplinary management of these patients throughout the perioperative period is essential in order to ensure the best surgical outcomes.
Abstract Background Metabolic alkalosis (MA) inhibits respiratory drive and may delay weaning from mechanical ventilation (MV). MA is common in CO2 -retainer patients that need MV. Acetazolamide ...(ACTZ) decreases serum bicarbonate concentration and stimulates respiratory drive. This study evaluated the effects of ACTZ on the duration of MV in patients with MA and COPD or obesity hypoventilation syndrome (OHS) intubated with acute respiratory failure. Methods Multicenter, randomized, controlled, double-blind study, with COPD or OHS patients with MV < 72 h and initial bicarbonate >28 mmol/L and pH > 7.35. Test-treatment, ACTZ 500 mg or placebo, was daily administered if pH > 7.35 and bicarbonate >26 mmol/L. Clinical, respiratory and laboratory parameters were recorded. Results 47 patients (36 men) were randomized. There were no significant differences between groups in comorbidities, baseline characteristics or arterial blood gases at inclusion. The mean difference in the duration of MV between placebo and ACTZ group was 1.3 days (95%CI, −2.1–4.8; p = 0.44). Kaplan-Meier curves showed no differences in the duration of MV (Log-Rank p = 0.41). Between-group comparison of estimated marginal means (CI 95%) during MV were, respectively: PaCO2 55 (51–59) vs 48 (47–50) mm Hg, p = 0.002; bicarbonate concentration 34 (32–35) vs 29 (28–30) mmol/L, p < 0.0001; and minute volume 9.7 (8.9–10.4) vs 10.6 (9.2–12.0) L/min, p = 0.26. There were no severe adverse effects with ACTZ administration. Conclusions Among patients with MA and COPD or OHS, early treatment with ACTZ did not shorten significantly the duration of MV compared with placebo. Trial registry clinical.trials.gov; NCT01499485 ; URL:. www.clinicaltrials.gov
Polypharmacy and risk of potentially inappropriate prescribing (PIP) in older adult are being continuously increased. Including a primary care pharmacist (PCP) in the healthcare team is associated ...with lower rates of medication-related problems (MRPs).
To determine the impact (in terms of variation of PIP, MRPs and polymedication) of treatment reviews (TR) carried out by the PCP by comparing two cohorts: standard TR vs coordinated TR with prescribing General Practitioners (GP). To assess possible health outcomes in both groups 6 months post-TR.
This is an observational study of two retrospective cohorts (2018 to 2020). All patients who met the inclusion/exclusion criteria were analyzed. Patients ≥65 years, who underwent complete TR by the PCP were included. Patients in a situation of exitus at the time of TR and those who underwent a partial TR were excluded. Control group cohort consisted of patients who underwent standard TR, and intervention group cohort consisted of those who underwent TR coordinated with GP. Sociodemographic, clinical and pharmacological variables were analyzed.
181 patients were enrolled. Mean age 84.4 ± 7.2 years, 78.5% women. Variables (GP-coordinated vs standard TRs) pre-post: decrease in drugs/patient 1.9 (95%CI: 1.4–2.4) vs 0.6 (95%CI: 0.2–1.3), p < 0.05; decrease in MRPs/patient 3.1 (95%CI: 2.8–3.4) vs 1.0 (95%CI: 0.6–1.4), p < 0.05; decrease in PIP/patient 2.0 (95% CI: 1.6–2.2) vs 0.6 (95% CI: 0.2–0.9), p < 0.05. Health outcomes: there was significant difference in average primary-care visits/patient 1.3 ± 0.5 vs 2.2 ± 1.8, p < 0.05.
Multidisciplinary interventions between PCP and GP, together with a systematic approach to TR can improve the quality of pharmacotherapy in the elderly. Prospective large follow-up studies are needed to demonstrate a positive trend in health outcomes.
The Javalambre-Physics of the Accelerating Universe Astrophysical Survey (J-PAS) will scan thousands of square degrees of the northern sky with a unique set of 56 filters using the dedicated 2.55 m ...Javalambre Survey Telescope (JST) at the Javalambre Astrophysical Observatory. Prior to the installation of the main camera (4.2 deg
2
field-of-view with 1.2 Gpixels), the JST was equipped with the JPAS-Pathfinder, a one CCD camera with a 0.3 deg
2
field-of-view and plate scale of 0.23 arcsec pixel
−1
. To demonstrate the scientific potential of J-PAS, the JPAS-Pathfinder camera was used to perform miniJPAS, a ∼1 deg
2
survey of the AEGIS field (along the Extended Groth Strip). The field was observed with the 56 J-PAS filters, which include 54 narrow band (
FWHM
∼ 145 Å) and two broader filters extending to the UV and the near-infrared, complemented by the
u
,
g
,
r
,
i
SDSS broad band filters. In this miniJPAS survey overview paper, we present the miniJPAS data set (images and catalogs), as we highlight key aspects and applications of these unique spectro-photometric data and describe how to access the public data products. The data parameters reach depths of mag
AB
≃ 22−23.5 in the 54 narrow band filters and up to 24 in the broader filters (5
σ
in a 3″ aperture). The miniJPAS primary catalog contains more than 64 000 sources detected in the
r
band and with matched photometry in all other bands. This catalog is 99% complete at
r
= 23.6 (
r
= 22.7) mag for point-like (extended) sources. We show that our photometric redshifts have an accuracy better than 1% for all sources up to
r
= 22.5, and a precision of ≤0.3% for a subset consisting of about half of the sample. On this basis, we outline several scientific applications of our data, including the study of spatially-resolved stellar populations of nearby galaxies, the analysis of the large scale structure up to
z
∼ 0.9, and the detection of large numbers of clusters and groups. Sub-percent redshift precision can also be reached for quasars, allowing for the study of the large-scale structure to be pushed to
z
> 2. The miniJPAS survey demonstrates the capability of the J-PAS filter system to accurately characterize a broad variety of sources and paves the way for the upcoming arrival of J-PAS, which will multiply this data by three orders of magnitude.
The use of peripheral venous catheters (PVCs) has increased outside intensive care units, as has the rate of PVC-associated-bloodstream infection (PVC-BSI). PVCs are widely used in internal medicine ...departments (IMDs), but data on the incidence of PVC-BSI and its characteristics in IMDs are scarce.
To assess the incidence of PVC-BSI episodes detected in IMDs in Spain.
A one-year multi-centre prospective observational cohort study in 14 Spanish IMDs was undertaken. Adult patients admitted with at least one PVC and bacteraemia were included in the study. Demographic and clinical data were provided by local coordinators.
Seventy episodes of PVC-BSI were recorded, representing an overall rate of 1.64 PVC-BSI episodes/1000 IMD admissions. The mean age of patients was 67.44 (standard deviation 16.72) years. It was estimated that 25.7% of PVCs were no longer necessary. Staphylococcus aureus was the most frequently isolated micro-organism (41.7%). Phlebitis was clinically evident in 44 (62.9%) episodes, and proved to be an independent predictor of catheter insertion in emergency departments (odds ratio 5.44). The crude and attributable mortality rates were 12.9% and 5.7%, respectively.
PVCs carry a significant risk for bacteraemia in Spanish IMDs. Phlebitis is not always clinically evident in patients with bacteraemia in this population. The study findings support the need for educational and interventional preventive measures in both IMDs and emergency departments to reduce the rate of PVC-BSI and associated comorbidities, and costs.
Neurologic manifestations are found in 5-15 % of patients with sarcoidosis. This granulomatous disease may affect any part of the peripheral or the central nervous system, being potentially severe ...and difficult to treat. Corticosteroids are the cornerstone of therapy in sarcoidosis. However, some patients become resistant or experience side effects to corticosteroids. In these patients, second line therapies including immunosuppressive drugs such as methotrexate, azathioprine, mycophenolate, cyclophosphamide and leflunomide have been used. Anti-TNF-α drugs have been proposed as a therapeutic option for those who are refractory to immunosuppressive drugs or initially in cases of severe sarcoidosis. We report on 5 patients with neurosarcoidosis treated with anti-TNF-α drugs in our center. A literature review of patients with neurosarcoidosis treated with anti-TNF-α drugs was conducted. In our series successful response to anti-TNF-α therapy was achieved. However, the high frequency of relapses following anti-TNF-α discontinuation makes necessary a close follow-up of these patients when the biologic agent is stopped.
Abstract
We report the discovery of a stellar overdensity 8° north of the centre of the Small Magellanic Cloud (SMC; Small Magellanic Cloud Northern Over-Density; SMCNOD), using data from the first ...2 yr of the Dark Energy Survey (DES) and the first year of the MAGellanic SatelLITEs Survey (MagLiteS). The SMCNOD is indistinguishable in age, metallicity and distance from the nearby SMC stars, being primarily composed of intermediate-age stars (6 Gyr, Z=0.001), with a small fraction of young stars (1 Gyr, Z=0.01). The SMCNOD has an elongated shape with an ellipticity of 0.6 and a size of ∼ 6° × 2°. It has an absolute magnitude of MV ≅ −7.7, rh = 2.1 kpc, and μV(r < rh) = 31.2 mag arcsec−2. We estimate a stellar mass of ∼105 M⊙, following a Kroupa mass function. The SMCNOD was probably removed from the SMC disc by tidal stripping, since it is located near the head of the Magellanic Stream, and the literature indicates likely recent Large Magellanic Cloud-SMC encounters. This scenario is supported by the lack of significant H i gas. Other potential scenarios for the SMCNOD origin are a transient overdensity within the SMC tidal radius or a primordial SMC satellite in advanced stage of disruption.
Several health organizations, mainly in Western countries, have recently authorized the use of a booster dose of the COVID-19 vaccine for patients previously vaccinated with mRNA vaccines, with ...criteria that do not always coincide. The COVID Scientific Committee of the Illustrious College of Physicians of Madrid (ICOMEM) has received and asked several questions about this situation, to which the group has tried to give answers, after deliberation and consensus. The efficacy of the vaccines administered so far is beyond doubt and they have managed to reduce, fundamentally, the severe forms of the disease. The duration of this protection is not well known, is different in different individuals and for different variants of the virus and is not easily predictable with laboratory tests. Data on the real impact of a supplementary or "booster" dose in the scientific literature are scarce for the moment and its application in large populations such as those in the state of Israel may be associated with a decrease in the risk of new and severe episodes in the short observation period available. We also lack sufficient data on the safety and potential adverse effects of these supplementary doses and we do not know the ideal time to administer them in different situations. In this state of affairs, it seems prudent to administer supplemental doses to those exposed to a higher risk, such as immunocompromised individuals and the elderly. On the other hand, we consider that this is not the time to accelerate, on the spur of the moment, a massive administration of a third dose to other population groups that are less exposed and at lower risk, without waiting for adequate scientific information, which will undoubtedly arrive gradually. We do not believe that this position is incompatible with the practical and ethical warnings made by the World Health Organization in this respect.
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