RESUMO
The use of a bougie, a flexible endotracheal tube introducer, has been proposed to optimize first-attempt success in emergency department intubations. We aimed to evaluate the available evidence on the association of bougie use in the first attempt and success in tracheal intubations. This was a systematic review and meta-analysis of studies that evaluated first-attempt success between adults intubated with a bougie versus without a bougie (usually with a stylet) in all settings. Manikin and cadaver studies were excluded. A medical librarian searched Ovid Cochrane Central, Ovid Embase, Ovid Medline, Scopus, and Web of Science for randomized controlled trials and comparative observational studies from inception to June 2023. Study selection and data extraction were done in duplicate by 2 independent reviewers. We conducted a meta-analysis with random-effects models, and we used GRADE to assess the certainty of evidence at the outcome level. We screened a total of 2,699 studies, and 133 were selected for full-text review. A total of 18 studies, including 12 randomized controlled trials, underwent quantitative analysis. In the meta-analysis of 18 studies (9,151 patients), bougie use was associated with increased first-attempt intubation success (pooled risk ratio [RR] 1.11, 95% confidence interval [CI] 1.06 to 1.17, low certainty evidence). Bougie use was associated with increased first-attempt success across all analyzed subgroups with similar effect estimates, including in emergency intubations (9 studies; 8,070 patients; RR 1.11, 95% CI 1.05 to 1.16, low certainty). The highest point estimate favoring the use of a bougie was in the subgroup of patients with Cormack-Lehane III or IV (5 studies, 585 patients, RR 1.60, 95% CI 1.40 to 1.84, moderate certainty). In this meta-analysis, the bougie as an aid in the first intubation attempt was associated with increased success. Despite the certainty of evidence being low, these data suggest that a bougie should probably be used first and not as a rescue device in emergency intubations.
Assuntos
Serviço Hospitalar de Emergência , Intubação Intratraqueal , Adulto , HumanosRESUMO
BACKGROUND: A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN. METHODS: We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed. RESULTS: From 149 titles, five systematic reviews were selected for quality assessment, and two reviews were of higher methodological quality and were included. These two reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of two RCTs including a total of 50 patients, the use of corticosteroids (compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% confidence interval [CI] 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide CI for the outcome of dizziness handicap score (one study, 30 patients, 20.9 points in corticosteroids group vs. 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low. CONCLUSIONS: There is limited evidence to support the use of corticosteroids for the treatment of VN in the emergency department.
Assuntos
Neuronite Vestibular , Adulto , Humanos , Corticosteroides/uso terapêutico , Tontura , Serviço Hospitalar de Emergência , Revisões Sistemáticas como Assunto , Vertigem , Neuronite Vestibular/diagnóstico , Neuronite Vestibular/tratamento farmacológicoRESUMO
Coffee (Coffea L.) is one of the main crops produced globally. Its contamination by the fungus Hemileia vastatrix Berkeley and Broome has been economically detrimental for producers. The objective of this work was to extract and characterize the essential oils from Eucalyptus citriodora Hook, Eucalyptus camaldulensis Dehn and Eucalyptus grandis Hill ex Maiden, produce and characterize nanoparticles containing these essential oils and evaluate the in vivo and in vitro antifungal activity of free and nanoencapsulated essential oils. The principal constituent of the essential oil from E. citriodora was citronellal; that from E. grandis was α-pinene; and that from E. camaldulensis was 1,8-cineol. The in vitro antifungal activity against the fungus H. vastatrix was 100% at a concentration of 1000 µl l-1 for all the oils and nanoparticles containing these natural products. The sizes of the nanoparticles produced with the essential oils from E. citriodora, E. camaldulensis and E. grandis were 402·13 nm, 275·33 nm and 328·5 nm, respectively, with surface charges of -11·8 mV, -9·24 mV and - 6·76 mV, respectively. Fourier transform infrared analyses proved that the encapsulation of essential oils occurred in the polymeric matrix of poly(ε-caprolactone). The incorporation of essential oils into biodegradable poly(ε-caprolactone) nanoparticles increased their efficiency as biofungicides in the fight against coffee rust, decreasing the severity of the disease by up to 90·75% after treatment with the nanoparticles containing the essential oil from E. grandis.
Assuntos
Eucalyptus , Nanopartículas , Óleos Voláteis , Antifúngicos/farmacologia , Basidiomycota , Eucaliptol , Óleos Voláteis/farmacologia , Óleos de Plantas , PoliésteresRESUMO
Essential oils encapsulated in a polymeric matrix can be used as an alternative method to control fungi and mycotoxins. The essential oils were extracted by hydrodistillation and characterized by gas chromatography. The nanofibres were produced from poly (acid lactic) (PLA) containing essential oils by the Solution Blow Spinning method. The antifungal and antimicotoxygenic properties were evaluated against Aspergillus ochraceus and Aspergillus westerdijkiae by the fumigation method. Terpinen-4-ol (20·23%), sabinene (20·18%), 1·8-cineole (16·69%) and γ-terpinene (11·03%) were the principal compounds present in the essential oil from Alpinia speciosa, whereas citral (97·67%) was dominant from Cymbopogon flexuosus. Microscopy images showed that the addition of essential oils caused an increase in the diameter of the nanofibres. The infrared spectroscopy results indicated the presence of essential oils in the PLA nanofibres. Differential scanning calorimetry curves also indicated the existence of interactions between the essential oils and polymeric macromolecules through their plasticizing action. The hydrophobic character of nanofibres was revealed by the contact angle technique. An antifungal effect was observed, the mycelial growths (3·25-100%) and the synthesis of ochratoxin A (25·94-100%) were inhibited by the presence of the nanofibres. The results suggest that bioactive nanofibres hold promise for application to control toxigenic fungi.
Assuntos
Alpinia , Cymbopogon , Nanofibras , Óleos Voláteis , Alpinia/química , Antifúngicos/farmacologia , Aspergillus , Cymbopogon/química , Fungos , Óleos Voláteis/química , Óleos Voláteis/farmacologia , PoliésteresRESUMO
BACKGROUND: Emergency medicine (EM) in Brazil has achieved critical steps toward its development in the last decades including its official recognition as a specialty in 2016. In this article, we worked in collaboration with the Brazilian Association of Emergency Medicine (ABRAMEDE) to describe three main aspects of EM in Brazil: (1) brief historical perspective; (2) current status; and (3) future challenges. MAIN TEXT: In Brazil, the first EM residency program was created in 1996. Only 20 years later, the specialty was officially recognized by national regulatory bodies. Prior to recognition, there were only 2 residency programs. Since then, 52 new programs were initiated. Brazil has now 54 residency programs in 16 of the 27 federative units. As of December 2020, 192 physicians have been board certified as emergency physicians in Brazil. The shortage of formal EM-trained physicians is still significant and at this point it is not feasible to have all Brazilian emergency care units and EDs staffed only with formally trained emergency physicians. Three future challenges were identified including the recognition of EM specialists in the house of Medicine, the need of creating a reliable training curriculum despite highly heterogeneous emergency care practice across the country, and the importance of fostering the development of academic EM as a way to build a strong research agenda and therefore increase the knowledge about the epidemiology and organization of emergency care. CONCLUSION: Although EM in Brazil has accomplished key steps toward its development, there are several obstacles before it becomes a solid medical specialty. Its continuous development will depend on special attention to key challenges involving recognition, reliability, and research.
RESUMO
OBJECTIVE: To evaluate the prognostic accuracy of qSOFA for predicting in-hospital mortality among patients with suspected infection presenting to the ED of a public tertiary hospital in Brazil. METHODS: We performed a retrospective cohort study of consecutive adult patients (age ≥ 18 years) with suspected infection who presented to an academic tertiary ED in Porto Alegre (Southern Brazil) during an 18-month period. The qSOFA was calculated by using information collected at triage and patients were followed throughout hospitalization for the primary outcome of in-hospital mortality. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratios with corresponding 95% CIs were calculated for the qSOFA and qSOFA65. RESULTS: A total of 7523 ED visits of patients with suspected infection in which an intravenous antibiotic was administered within 24 h were included, which resulted in 908 in-hospital deaths (12.1%). There were 690 (9.2%) patients whose triage qSOFA was ≥2 points. When such cutoff was used, the sensitivity for in-hospital death was 24.6% (95% CI 21.8 to 27.4%) and the specificity was 92.9% (95% CI 92.3% to 93.5%). The sensitivity increased to 67.4% (95% CI 64.2% to 70.3%) when a cutoff of ≥1 was tested, but the specificity decreased to 55.3% (95% CI 54.1% to 56.5%). Using a cutoff of ≥2, the qSOFA65 had a sensitivity of 51.0% (95% CI 47.7% to 54.3%) and a specificity of 75.7% (95% CI 74.6% to 76.7%). CONCLUSIONS: The qSOFA score yielded very low sensitivity in predicting in-hospital mortality. Emergency physicians or ED triage nurses in low-to-middle income countries should not be using qSOFA or qSOFA65 as "rule-out" screening tools in the initial evaluation of patients with suspected infection.
Assuntos
Serviço Hospitalar de Emergência , Mortalidade Hospitalar , Infecções/mortalidade , Escores de Disfunção Orgânica , Idoso , Antibacterianos/administração & dosagem , Brasil/epidemiologia , Feminino , Humanos , Infecções/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Sensibilidade e Especificidade , TriagemRESUMO
OBJECTIVE: To characterize pediatric Emergency Medicine Service (EMS) transports to the Emergency Department (ED) using a national claims database. METHODS: We included children, 18â¯years and younger, transported by EMS to an ED, from 2007 to 2016 in the OptumLabs Data Warehouse. ICD-9 and ICD-10 diagnosis codes were used to categorize disease system involvement. Interventions performed were extracted using procedure codes. ED visit severity was measured by the Minnesota Algorithm. RESULTS: Over a 10-year period, 239,243 children were transported. Trauma was the most frequent diagnosis category for transport for children ≥5â¯years of age, 35.1% (age 6-13) and 32.7% (age 14-18). The most common diagnosis category in children <6â¯years of age was neurologic (29.3%), followed by respiratory (23.1%). Over 10â¯years, transports for mental disorders represented 15.3% in children age 14 to 18, and had the greatest absolute increase (rate differenceâ¯+â¯10.4 per 10,000) across all diagnoses categories. Neurologic transports also significantly increased in children age 14 to 18 (rate differenceâ¯+â¯6.9 per 10,000). Trauma rates decreased across all age groups and had its greatest reduction among children age 14 to 18 (rate differenceâ¯-â¯6.8 per 10,000). Across all age groups, an intervention was performed in 15.6%. Most children (83.3%) were deemed to have ED care needed type of visit, and 15.8% of the transports resulted in a hospital admission. CONCLUSION: Trauma is the most frequent diagnosis for transport in children older than 5â¯years of age. Mental health and neurologic transports have markedly increased, while trauma transports have decreased. Most children arriving by ambulance were classified as requiring ED level of care. These changes might have significant implication for EMS personnel and policy makers.
Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Setor Privado/estatística & dados numéricos , Transporte de Pacientes/estatística & dados numéricos , Adolescente , Distribuição por Idade , Ambulâncias/estatística & dados numéricos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Revisão da Utilização de Seguros , Masculino , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/terapia , Transtornos do Neurodesenvolvimento/epidemiologia , Transtornos do Neurodesenvolvimento/terapia , Doenças Respiratórias/epidemiologia , Doenças Respiratórias/terapia , Distribuição por Sexo , Estados Unidos/epidemiologia , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/terapiaRESUMO
A strain of embryonic human kidney cells (HEK293) was transiently co-transfected with the expression vectors coding for the α- and ß-subunits of human thyroid-stimulating hormone (hTSH), and, for the first time, a human cell-derived recombinant hTSH was synthesized and extensively characterized. The purification strategy involving two steps provided an overall yield of 55% and a purity level > 90%. The purified material (hTSH-HEK) was analyzed and compared to a CHO-derived recombinant preparation (hTSH-CHO) and to a pituitary-derived (hTSH-Pit) preparation. The three preparations showed an equivalent purity (> 95%) with a hTSH-HEK molecular mass 2.1% lower than that of hTSH-CHO and 2.7% higher than that of hTSH-Pit. Remarkable differences were found in the carbohydrate moiety, the lowest sialic acid content and highest fucose content being observed in hTSH-HEK. In vivo biological activity was confirmed for the three preparations, the hTSH-HEK bioactivity being 39 and 16% lower than those of hTSH-CHO and hTSH-Pit, respectively. The hTSH-HEK circulatory half-life (t 1/2) was also shorter than those of hTSH-CHO (1.5-fold) and hTSH-Pit (1.2-fold). According to these findings, HEK-293-derived hTSH can be considered to be useful for clinical applications, in view as well of its human origin and particular carbohydrate composition.
Assuntos
Carboidratos/análise , Células Epiteliais/metabolismo , Glicoproteínas/biossíntese , Tireotropina/biossíntese , Animais , Células CHO , Cricetinae , Cricetulus , Fucose/análise , Glicosilação , Células HEK293 , Meia-Vida , Humanos , Ácido N-Acetilneuramínico/análise , Proteínas Recombinantes/biossíntese , Espectrometria de Massas por Ionização e Dessorção a Laser Assistida por Matriz , TransfecçãoRESUMO
STUDY OBJECTIVE: We conduct a systematic review and meta-analysis to evaluate the effectiveness of apneic oxygenation during emergency intubation. METHODS: We searched Ovid MEDLINE, Ovid EMBASE, Ovid CENTRAL, and Scopus databases for randomized controlled trials and observational studies from 2006 until July 2016, without language restrictions. Gray literature, clinicaltrials.gov, and reference lists of articles were hand searched. We conducted a meta-analysis with random-effects models to evaluate first-pass success rates, incidence of hypoxemia, and lowest peri-intubation SpO2 between apneic oxygenation and standard oxygenation cases. RESULTS: A total of 1,386 studies were screened and 77 selected for full-text review. A total of 14 studies were included for qualitative analysis, and 8 studies (1,837 patients) underwent quantitative analysis. In the meta-analysis of 8 studies (1,837 patients), apneic oxygenation was associated with decreased hypoxemia (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.52 to 0.84), but was not associated with decreased severe hypoxemia (6 studies; 1,043 patients; OR 0.86; 95% CI 0.47 to 1.57) or life-threatening hypoxemia (5 studies; 1,003 patients; OR 0.90; 95% CI 0.52 to 1.55). Apneic oxygenation was associated with increased first-pass success rate (6 studies; 1,658 patients; OR 1.59; 95% CI 1.04 to 2.44) and increased lowest peri-intubation SpO2 (6 studies; 1,043 patients; weighted mean difference 2.2%; 95% CI 0.8% to 3.6%). CONCLUSION: In this meta-analysis, apneic oxygenation was associated with increased peri-intubation oxygen saturation, decreased rates of hypoxemia, and increased first-pass intubation success.