Purpose
The role of dobutamine during septic shock resuscitation is still controversial since most clinical studies have been uncontrolled and no physiological study has unequivocally demonstrated a ...beneficial effect on tissue perfusion. Our objective was to determine the potential benefits of dobutamine on hemodynamic, metabolic, peripheral, hepatosplanchnic and microcirculatory perfusion parameters during early septic shock resuscitation.
Methods
We designed a randomized, controlled, double-blind, crossover study comparing the effects of 2.5-h infusion of dobutamine (5 mcg/kg/min fixed-dose) or placebo in 20 septic shock patients with cardiac index ≥2.5 l/min/m
2
and hyperlactatemia. Primary outcome was sublingual perfused microvascular density.
Results
Despite an increasing cardiac index, heart rate and left ventricular ejection fraction, dobutamine had no effect on sublingual perfused vessel density 9.0 (7.9–10.1) vs. 9.1 n/mm (7.9–9.9);
p
= 0.24 or microvascular flow index 2.1 (1.8–2.5) vs. 2.1 (1.9–2.5);
p
= 0.73 compared to placebo. No differences between dobutamine and placebo were found for the lactate levels, mixed venous-arterial pCO
2
gradient, thenar muscle oxygen saturation, capillary refill time or gastric-to-arterial pCO
2
gradient. The indocyanine green plasma disappearance rate 14.4 (9.5–25.6) vs. 18.8 %/min (11.7–24.6);
p
= 0.03 and the recovery slope of thenar muscle oxygen saturation after a vascular occlusion test 2.1 (1.1–3.1) vs. 2.5 %/s (1.2–3.4);
p
= 0.01 were worse with dobutamine compared to placebo.
Conclusions
Dobutamine failed to improve sublingual microcirculatory, metabolic, hepatosplanchnic or peripheral perfusion parameters despite inducing a significant increase in systemic hemodynamic variables in septic shock patients without low cardiac output but with persistent hypoperfusion.
The following scoping review is aimed at identifying leadership competency frameworks in Undergraduate Medical Education (UME) by analyzing the thematic scopes, target audiences, and methods ...involved. A further objective is to compare the frameworks against a standard framework.
The authors extracted the thematic scope and methods of each framework based on the original author's formulations in each selected paper. The target audience was divided into three sections: UME, medical education, and beyond medical education. The frameworks were converged and diverged against the public health leadership competency framework.
Thirty-three frameworks covering thematic scopes such as refugees and migrants were identified. The most common methods to develop leadership frameworks were reviews and interviews. The courses targeted multiple disciplines including medicine and nurses. The identified competency frameworks have not converged among important domains of leadership such as systems thinking, political leadership, leading change, and emotional intelligence.
There is a variety of frameworks that support leadership in UME. Nevertheless, they are not consistent in vital domains to face worldwide health challenges. Interdisciplinary and transdisciplinary leadership competency frameworks which address health challenges should be used in UME.
El incremento del número de vehículos terrestres particulares, de carga y transporte masivo, y la ausencia de planificación y proyección de las vías en el pasado, han generado graves problemas de ...congestión, aumento de la accidentalidad, inseguridad y desinformación de los usuarios de este tipo de transporte. Los gobiernos y las entidades descentralizadas han venido diseñando sistemas de comunicación entre vehículos con acceso a redes Wan o Internet, que permiten a conductores y pasajeros obtener información en tiempo real acerca del estado de las vías, peajes, rutas optimas e incluso acceso a material informativo de la zona por la que se transita, para hacer el viaje mas seguro y placentero. En este trabajo se describe el estado actual de las tecnologías inalámbricas para la comunicación de las redes vehiculares de última generación, haciendo comparativos entre las tecnologías empleadas a bordo del vehículo y fuera de este. También se muestra el estado del arte en las principales arquitecturas diseñadas en Europa y Estados unidos, que se encuentran en fase de estudio e implementación.
Lactoferrin (LF) has in vitro antiviral activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study aimed to determine the effect of bovine lactoferrin (bLF) in the ...prevention of SARS-CoV-2 infection in health care personnel. A randomized, double-blinded, placebo-controlled clinical trial was conducted in two tertiary hospitals that provide care to patients with SARS-CoV-2 infection in Lima, Peru. Daily supplementation with 600 mg of enteral bLF versus placebo for 90 days was compared. Participants were weekly screened for symptoms suggestive of SARS-CoV-2 infection and molecular testing was performed on suspected episodes. A serological test was obtained from all participants at the end of the intervention. The main outcome included symptomatic and asymptomatic cases. A sub-analysis explored the time to symptomatic infection. Secondary outcomes were the severity, frequency, and duration of symptomatic infection. The study was prematurely cancelled due to the availability of vaccines against SARS-CoV-2 in Peru. 209 participants were enrolled and randomized, 104 received bLF and 105 placebo. SARS-CoV-2 infection occurred in 11 (10.6%) participants assigned to bLF and in 9 (8.6%) participants assigned to placebo without significant differences (Incidence Rate Ratio = 1.23, 95%CI 0.51–3.06, p-value = 0.64). There was no significant effect of bLF on time to symptomatic infection (Hazard Ratio = 1.61, 95%CI 0.62–4.19, p-value = 0.3). There were no significant differences in secondary outcomes. A significant effect of bLF in preventing SARS-CoV-2 infection was not proven. Further studies are needed to assess the effect of bLF supplementation on SARS-CoV-2 infection.
Clinical trial registration
ClinicalTrials.gov Identifier: NCT04526821,
https://clinicaltrials.gov/ct2/show/NCT04526821?term=LACTOFERRIN&cond=COVID-19&cntry=PE&city=Lima&draw=2&rank=1
.
ABSTRACT Background: Scleroderma renal crisis is a condition that affects approximately 4-6% of patients with systemic sclerosis, especially with diffuse compromise. Clinical manifestations are ...variable, representing a diagnostic challenge. Objective: The study aims to describe and analyze the different pharmacological treatments available for the management of scleroderma renal crisis. Materials and methods: A systematic literature review was done based on observational studies and clinical trials about the treatment of scleroderma renal crisis, using monotherapy or combined therapy. The studies were identified using electronic scientific databases, including MEDLINE PUBMED and EMBASE, in English, published between January 1990 and August 2019. Results: Eleven studies were included (ten observational studies and one open clinical trial). Of them, seven were cohorts, one case series, and two case-control studies. Overall, 1113 patients were included in the analyzed studies. All studies used angiotensin-converting enzyme inhibitors as exposition, case definition, and/or comparison in the clinical trial. Regarding the need for dialysis, approximately 53.9% of patients required it temporarily or permanently. Approximately 6-27% of patients required temporal dialysis, and 19-78% required permanent dialysis. One-year survival range was between 64 and 84%; two-year survival was between 53 and 74%; five-year survival between 40 and 90%, and finally ten-year survival between 35 and 47%. Conclusions: Angiotensin-converting enzyme inhibitors continue to be the first line of treatment for scleroderma renal crisis by contributing to a decrease in short-term mortality. However, alternative therapeutic options are required as a high percentage of patients still require dialysis. Future clinical trials are necessary to assess the effectiveness and safety of different therapeutic options.
Temporal discounting is a phenomenon where a reward loses its value as a function of time (e.g., a reward is more valuable immediately than when it delays in time). This is a type of intertemporal ...decision-making that has an association with impulsivity and self-control. Many pathologies exhibit higher discounting rates, meaning they discount more the values of rewards, such as addictive behaviors, bipolar disorder, attention-deficit/hyperactivity disorders, social anxiety disorders, and major depressive disorder, among others; thus, many studies look for the mechanism and neuromodulators of these decisions. This systematic review aims to investigate the association between pharmacological administration and changes in temporal discounting. A search was conducted in PubMed, Scopus, Web of Science, Science Direct and Cochrane. We used the PICO strategy: healthy humans (P-Participants) that received a pharmacological administration (I-Intervention) and the absence of a pharmacological administration or placebo (C-Comparison) to analyze the relationship between the pharmacological administration and the temporal discounting (O-outcome). Nineteen studies fulfilled the inclusion criteria. The most important findings were the involvement of dopamine modulation in a U-shape for choosing the delayed outcome (metoclopradime, haloperidol, and amisulpride). Furthermore, administration of tolcapone and high doses of d-amphetamine produced a preference for the delayed option. There was a time-dependent hydrocortisone effect in the preference for the immediate reward. Thus, it can be concluded that dopamine is a crucial modulator for temporal discounting, especially the D2 receptor, and cortisol also has an important time-dependent role in this type of decision. One of the limitations of this systematic review is the heterogeneity of the drugs used to assess the effect of temporal discounting.
In 2010, 240 billion US dollars was invested worldwide to conduct research for health; unfortunately, 200 billion was misused in the production and reporting of the evidence researched. Universities ...could facilitate students to acquire leadership competencies to move well-conducted research findings into practical use; this could be an essential move to reduce the misuse of investment.
A literature review was done based on the Equator Network and Cochrane guidelines, followed by three Delphi rounds to select competencies.
Eleven papers were analysed out of 1121 items and 39/78 identified competencies were prioritized to be presented in the Delphi. Four out of 12 participants accepted to be involved in this project, and 22 competencies reached consensus and stability after three rounds. This framework conceptualizes competencies as the knowledge, skills, attitudes and values. The competencies were framed in four domains: knowledge management, engage diverse others in public health initiatives, training and capacity building/change management and communication.
This framework offers guidance to universities when instructing students with leadership competencies for KT. This project emphasizes that effective leadership should include personal conscience and self-determination values.
Air pollution in most countries exceeds the levels recommended by the World Health Organization, causing up to one-third of deaths due to noncommunicable diseases. Fine particulate matter (PM
) and ...black carbon (BC) from mobile sources are the main contaminants.
The aim of this study is to assess the relationship of exposure to air pollutants (PM
and BC) in microenvironments according to respiratory health and physical activity in users traveling by different types of transportation in Bogotá, Colombia.
A mixed methods study based on a convergent parallel design will be performed with workers and students. The sample will include 350 healthy transport users traveling by different urban transportation modes in three main routes in Bogotá. The study is broken down into two components: (1) a descriptive qualitative component focused on assessing the individual perception of air pollution using semistructured interviews; and (2) a cross-sectional study measuring the individual exposure to PM
and BC using portable instruments (DustTrak and microAeth, respectively), pulmonary function by spirometry, and physical activity with accelerometry. The analysis will include concurrent triangulation and logistic regression.
The findings will be useful for the conception, design, and decision-making process in the sectors of health and mobility from public, academy, and private perspectives. This study includes personal measurements of PM
and BC during typical trips in the city to assess the exposure to these contaminants in the major roadways in real time. The study further compares the performance of two different lung tests to identify possible short-term respiratory effects. As a limitation, the protocol will include participants from different institutions in the city, which are not necessarily representative of all healthy populations in Bogotá. In this sense, it is not possible to draw causation conclusions. Moreover, a convergent parallel design could be especially problematic concerning integration because such a design often lacks a clear plan for making a connection between the two sets of results, which may not be well connected. Nevertheless, this study adopts a procedure for how to integrate qualitative and quantitative data in the interpretation of the results and a multilevel regression. The time that participants must live in the city will be considered; this will be controlled in the stratified analysis. Another limitation is the wide age range and working status of the participants. Regional pollution levels and episodes (PM
) will be handled as confounding variables. The study is currently in the enrollment phase of the participants. Measurements have been made on 300 participants. Pandemic conditions affected the study schedule; however, the results are likely to be obtained by late 2022.
This study investigates the exposure to air pollutants in microenvironments in Bogotá, Colombia. To our knowledge, this is the first mixed methods study focusing on PM
, BC, and respiratory health effects in a city over 2 meters above sea level. This study will provide an integration of air pollution exposure variables and respiratory health effects in different microenvironments.
PRR1-10.2196/25690.
Introduction
Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an ...almost complete lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems.
Material and methods
This is an inter‐continental, multicenter, descriptive, retrospective study in low‐ and middle‐income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated.
Results
Eighty‐two maternal deaths in 16 low‐ and middle‐income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases.
Conclusions
Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.
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