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Objective: Evaluate the incidence of hypotension during the weaning phase of vasopressors., Design: A single-center, open-label randomized clinical trial between May and December 2022., Setting: a tertiary care academic medical center., Patients: 91 adult patients over 18 years of age with septic shock (according to Sepsis-3)., Intervention: Patients were divided into two groups: initial reduction of norepinephrine or initial reduction of vasopressin., Main Variables of Interest: The primary outcome was the incidence of hypotension within the first 24 h after reducing vasopressors. Additionally, the clinical impact of this hypotension was assessed through mortality, length of hospital stay, duration of vasopressor use, incidence of arrhythmias, and prevalence of hemodialysis., Results: Out of a total of 91 patients, 78 were included in the analysis: 39 in the norepinephrine group and 39 in the vasopressin group. Despite a numerically significant difference in the incidence of hypotension between the groups (norepinephrine 43.6%, vasopressin 25.6%), there was no statistical difference (p =  0.153, relative risk = 1.7, 95% confidence interval: 0.9-3.2). In this sample, vasopressin withdrawal was predominantly titrated. There were no differences between the groups in terms of the evaluated clinical outcomes., Conclusion: No differences were detected in the incidence of hypotension when weaning was initiated with norepinephrine or vasopressin, although it was non significantly higher in norepinephrine group. In our sample, vasopressin withdrawal was titrated, which differs from North American practice. Brazilian Clinical Trials Registry (REBEC: RBR-10smbw65)., Clinicaltrials: gov platform (NCT05506319)., (Copyright © 2025 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.)

Objective: to evaluate three methods of nasogastric tube fixation in terms of adhesion, displacement and skin integrity., Method: ex vivo study, with a sample of 30 experimental noses (10 for each type of fixation), developed with porcine skin, based on the average measurements of the human nose, in which 14-gauge polyvinyl chloride probes were inserted and 2 methods of fixation with adhesive tape (Fixation A and B) and one with an industrial device (Fixation C) were used. Each group was exposed to traction of 50, 100 and 500g sequentially over 12 and 24 hours, testing: adhesion capacity, probe displacement and skin integrity. The Chi-square test of independence was calculated for nominal variables and Student's t-tests and analysis of variance (p< 0.05) for rational variables., Results: fixation B showed lower adhesion capacity (p <0.001) when compared to the other two fixations. A mean displacement of 52.17 mm was observed in the probes fixed by methods A and B and a greater occurrence of lesions associated with fixations A and C (p = 0.001)., Conclusion: the results show complications related to the fixations: lack of adhesion, displacement of the probe and skin lesions, drawing attention to the complexity of the procedure.

Objective: To evaluate the association of biomarkers with successful ventilatory weaning in COVID-19 patients., Methods: An observational, retrospective, and single-center study was conducted between March 2020 and April 2021. C-reactive protein, total lymphocytes, and the neutrophil/lymphocyte ratio were evaluated during attrition and extubation, and the variation in these biomarker values was measured. The primary outcome was successful extubation. ROC curves were drawn to find the best cutoff points for the biomarkers based on sensitivity and specificity. Statistical analysis was performed using logistic regression., Results: Of the 2,377 patients admitted to the intensive care unit, 458 were included in the analysis, 356 in the Successful Weaning Group and 102 in the Failure Group. The cutoff points found from the ROC curves were -62.4% for C-reactive protein, +45.7% for total lymphocytes, and -32.9% for neutrophil/lymphocyte ratio. These points were significantly associated with greater extubation success. In the multivariate analysis, only C-reactive protein variation remained statistically significant (OR 2.6; 95%CI 1.51 - 4.5; p < 0.001)., Conclusion: In this study, a decrease in C-reactive protein levels was associated with successful extubation in COVID-19 patients. Total lymphocytes and the neutrophil/lymphocyte ratio did not maintain the association after multivariate analysis. However, a decrease in C-reactive protein levels should not be used as a sole variable to identify COVID-19 patients suitable for weaning; as in our study, the area under the ROC curve demonstrated poor accuracy in discriminating extubation outcomes, with low sensitivity and specificity.

Aim and Background: Hyperglycemia is considered an adaptive metabolic manifestation of stress and is associated with poor outcomes. Herein, we analyzed the association between glycemic variability (GV) and hospital mortality in patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU), and the association between GV and mechanical ventilation (MV), ICU stay, length of hospital stays, renal replacement therapy (RRT), hypoglycemia, nosocomial infections, insulin use, and corticosteroid class., Materials and Methods: In this retrospective observational study, we collected information on blood glucose levels during the first 10 days of hospitalization in a cohort of ICU patients with COVID-19 and its association with outcomes., Results: In 239 patients, an association was observed between GV and hospital mortality between the first and last quartiles among patients without diabetes [odds ratio (OR), 3.78; confidence interval, 1.24-11.5]. A higher GV was associated with a greater need for RRT ( p = 0.002), regular insulin ( p < 0.001), and episodes of hypoglycemia ( p < 0.001). Nosocomial infections were associated with intermediate GV quartiles ( p = 0.02). The corticosteroid class had no association with GV ( p = 0.21)., Conclusion: Glycemic variability was associated with high mortality in patients with COVID-19 and observed in the subgroup of patients without diabetes., Clinical Significance: Glycemic control in critically ill patients remains controversial and hyperglycemia is associated with worse outcomes. Diabetes mellitus (DM) is one of the most prevalent comorbidities in patients with COVID-19. In addition, they require corticosteroids due to pulmonary involvement, representing a challenge and an opportunity to better understand how glycemic changes can influence the outcome of these patients., How to Cite This Article: Boschi E, Friedman G, Moraes RB. Effects of Glycemic Variability in Critically Ill Patients with Coronavirus Disease 2019: A Retrospective Observational Study. Indian J Crit Care Med 2024;28(4):381-386., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2024; The Author(s).)

Importance: The effectiveness of goal-directed care to reduce loss of brain-dead potential donors to cardiac arrest is unclear., Objective: To evaluate the effectiveness of an evidence-based, goal-directed checklist in the clinical management of brain-dead potential donors in the intensive care unit (ICU)., Design, Setting, and Participants: The Donation Network to Optimize Organ Recovery Study (DONORS) was an open-label, parallel-group cluster randomized clinical trial in Brazil. Enrollment and follow-up were conducted from June 20, 2017, to November 30, 2019. Hospital ICUs that reported 10 or more brain deaths in the previous 2 years were included. Consecutive brain-dead potential donors in the ICU aged 14 to 90 years with a condition consistent with brain death after the first clinical examination were enrolled. Participants were randomized to either the intervention group or the control group. The intention-to-treat data analysis was conducted from June 15 to August 30, 2020., Interventions: Hospital staff in the intervention group were instructed to administer to brain-dead potential donors in the intervention group an evidence-based checklist with 13 clinical goals and 14 corresponding actions to guide care, every 6 hours, from study enrollment to organ retrieval. The control group provided or received usual care., Main Outcomes and Measures: The primary outcome was loss of brain-dead potential donors to cardiac arrest at the individual level. A prespecified sensitivity analysis assessed the effect of adherence to the checklist in the intervention group., Results: Among the 1771 brain-dead potential donors screened in 63 hospitals, 1535 were included. These patients included 673 males (59.2%) and had a median (IQR) age of 51 (36.3-62.0) years. The main cause of brain injury was stroke (877 [57.1%]), followed by trauma (485 [31.6%]). Of the 63 hospitals, 31 (49.2%) were assigned to the intervention group (743 [48.4%] brain-dead potential donors) and 32 (50.8%) to the control group (792 [51.6%] brain-dead potential donors). Seventy potential donors (9.4%) at intervention hospitals and 117 (14.8%) at control hospitals met the primary outcome (risk ratio [RR], 0.70; 95% CI, 0.46-1.08; P = .11). The primary outcome rate was lower in those with adherence higher than 79.0% than in the control group (5.3% vs 14.8%; RR, 0.41; 95% CI, 0.22-0.78; P = .006)., Conclusions and Relevance: This cluster randomized clinical trial was inconclusive in determining whether the overall use of an evidence-based, goal-directed checklist reduced brain-dead potential donor loss to cardiac arrest. The findings suggest that use of such a checklist has limited effectiveness without adherence to the actions recommended in this checklist., Trial Registration: ClinicalTrials.gov Identifier: NCT03179020.

The aim of this study was to characterize the normality of the fetal circulatory system through the time between ventricular systoles of the ductus venosus in the three gestational trimesters in healthy fetuses using nonlinear methods of the complexity of the signal. A prospective cohort study was conducted at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) from December 2019 to May 2020. Pregnant women between 11 and 14 weeks, with intrauterine pregnancy and healthy fetus were included. Patients with multiple gestation, positive screening for congenital malformation, including heart disease, and under 18 years of age were excluded. Doppler velocimetry ultrasonography of the ductus venosus was performed between the 11th and 14th weeks, 20th and 24th weeks, and 28th and 32nd weeks of gestation, and then the sound signal was extracted and segmented from the videos. To compare the means between the gestational trimesters of the approximate entropy (ApEn) and Lempel-Ziv complexity (CLZ) of the time between ventricular systoles, the Friedman test was used, with a significance level of 5%. No statistically significant difference was found between the 1st, 2nd, and 3rd trimesters regarding the mean ApEn (P=0.281) and CLZ (P=0.595) of the time between ventricular systoles of the ductus venosus. Ductus venosus systolic time was not sensitive to differentiate fetal cardiovascular dynamics between gestational trimesters. This study pioneered the characterization of cardiovascular normality by nonlinear parameters of the fetal ductus venosus in all three trimesters.

Objectives: We carried out this work with the aim of assessing the effectiveness of a set of interventions over time for the administration of antibiotics., Design: Prospective observational study., Setting: Patients admitted to the emergency room and ICU of the hospital where the study was conducted are evaluated daily for some sociodemographic and clinical variables. Among them are some quality indicators, such as the time between the diagnosis of sepsis or septic shock until the start of the infusion of antibiotics. This indicator reflects several aspects related to a set of assistance measures (adequacy of antibiotic dispensation, rapid response team (RRT), sepsis care quality improvement program, antimicrobial management program, improvements in emergency department assistance)., Patients or Participants: Patients with sepsis or septic shock were admitted to the ICU of a university and public hospital in southern Brazil., Main Variables of Interest: The time between the diagnosis of sepsis or septic shock and the beginning of the infusion of antibiotics., Results: Between 2013 and 2018, 1676 patients were evaluated. The mean time for antibiotic infusion decreased from 6.1 ± 8.6 hours to 1.7 ± 2.9 hours ( p < 0.001). The percentage of patients who received antibiotics in the first hour increased from 20.7 to 59.0% ( p < 0.001)., Conclusion: In this study, we demonstrated that a set of actions adopted in a large tertiary hospital was associated with decreased time to start antibiotic therapy in septic patients., How to Cite This Article: Moraes RB, Haas JS, Vidart J, Nicolaidis R, Deutschendorf C, Moretti MMS, et al . A Coordinated and Multidisciplinary Strategy can Reduce the Time for Antibiotics in Septic Patients at a University Hospital. Indian J Crit Care Med 2023;27(7):465-469., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2023; The Author(s).)

Backcground & Aims: There in no data regarding outcomes after hospital discharge for underweight critically ill patients. This study aimed to assess long-term survival and functional capacity in underweight critically ill patients., Materials & Methods: Prospective observational study that included underweight critically ill patients (BMI <20 kg/cm 2 ) followed-up one year after hospital discharge. To assess functional capacity, we interviewed patients or caregivers and performed Katz index (KI) and Lawton scale. Patients were divided into two groups: (1) poor functional capacity, if the patient had less points than the median of the Katz and IADL score, and (2) good functional capacity, if at least one score was above the median. Extremely low weight defined as less than 45 kg., Results: We assessed the vital status of 103 patients. Mortality was 38.8% (median 362 [136, 422] days of follow-up). We interviewed 62 patients or proxies. No difference was observed between survivors and non-survivors regarding weight and BMI at intensive care unit admission and nutritional therapy received in the first days of intensive care admission. Patients with poor functional capacity had lower admission weight (43.9 vs 52 ± 7.9 kg, p < 0.001) and BMI (17 ± 2.1 vs 18.2 ± 1.8 kg/cm 2 , p = 0.028). In a multivariate logistic regression, weight under 45 kg was independently associated with poor functional capacity (OR = 13.6, 95%CI, 3.7 to 66.5) CONCLUSION: Underweight critically ill patients have high mortality and a persistent functional impairment, the last being more important in extremely low weight., Clinical Trial Registry: ClinicalTrials.gov number NCT03398343., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2023 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Objective: Evaluate the impact of the availability of public dental care service on the increment of dental caries in children., Methods: This is a 2-year cohort study that followed preschool children from southern Brazil. Dental caries was measured at baseline and follow-up evaluation, considering the number of surfaces with untreated dental caries. Demographic and socioeconomic characteristics as well as the use and availability of dental services were assessed. Multilevel Poisson regression analysis through a hierarchical approach and considering a random effect for repeated measures was used to explore the influence of exploratory variables in the increase in the outcome., Results: A total of 419 cases were evaluated at follow-up (91.3% cohort retention rate). The increase in the untreated dental caries was associated with living in places where there is no regular presence of dentists in the public health system. In addition, the increment of dental caries was influenced by age, household income, and dental attendance., Conclusion: The results suggest that the availability of dentists in the public health system have an impact the increment of dental caries among children. The integration of the dentist in the primary healthcare can contribute to decrease the barriers that lead to children's oral health., (© 2020 American Association of Public Health Dentistry.)

Objectives: To investigate whether the effect of a flexible ICU visiting policy that includes flexible visitation plus visitor education on anxiety symptoms of family members is mediated by satisfaction and involvement in patient care., Design: We embedded a multivariable path mediation analysis within a cluster-randomized crossover trial as a secondary analysis of The ICU Visits Study (ClinicalTrials.gov number: NCT02932358)., Setting: Thirty-six medical-surgical ICUs in Brazil., Patients: Closest relatives of adult ICU patients., Interventions: Flexible visitation (12 hr/d) supported by family education or usual restricted visitation (median, 1.5 hr/d)., Measurements and Main Results: Overall, 863 family members were assessed (mean age, 44.7 yr; women, 70.1%). Compared with the restricted visitation (n = 436), flexible visitation (n = 427) resulted in better mean anxiety scores (6.1 vs 7.8; mean difference, -1.78 [95% CI, -2.31 to -1.22]), as well as higher standardized scores of satisfaction (67% [95% CI, 55-79]) and involvement in patient care (77% [95% CI, 64-89]). The mediated effect of flexible visitation on mean anxiety scores through each incremental sd of satisfaction and involvement in patient care were -0.47 (95% CI, -0.68 to -0.24) and 0.29 (95% CI, 0.04-0.54), respectively. Upon exploratory analyses, emotional support, helping the ICU staff to understand patient needs, helping the patient to interpret ICU staff instructions, and patient reorientation were the domains of involvement in patient care associated with increased anxiety., Conclusions: A flexible ICU visiting policy reduces anxiety symptoms among family members and appears to work by increasing satisfaction. However, increased participation in some activities of patient care as a result of flexible visitation was associated with higher severity of anxiety symptoms., Competing Interests: Drs. Rosa, Sganzerla, Schneider, Robinson, Kochhann, da Silva, Medeiros, and Falavigna report grants from Brazilian Ministry of Health during the conduct of study. Drs. Rosa’s, Sganzerla’s, and Medeiros’s institutions received funding from Brazilian Ministry of Health. Dr. da Silva received funding from Brazilian Ministry of Health. Dr. Amaral’s institution received funding from Hospital Moinhos de Vento. Drs. Amaral, Prestes, and Medeiros disclosed government work. Dr. Prestes’ institution received funding from Hospital Universitário da Universidade Federal do Piauí. Dr. Falavigna received funding from Roche, Novartis, Abbvie, Boehringer Ingelheim, Ultragenix, PTC Therapeutics, and Sanofi Genzime, and he received support for article research from the Canadian Institutes of Health Research. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Most of the Brazilian population is covered by the Family Health Strategy (FHS), however no longitudinal study has assessed the impact of the FHS on child oral health-related quality of life (OHRQoL). The objective of the study was to evaluate the longitudinal impact of the FHS on the OHRQoL. This study followed up 459 children aged 2 to 5 years for 2 years. OHRQoL was assessed by the Brazilian version of the Early Childhood Oral Health Impact Scale (ECOHIS) at baseline (April to November 2016) and follow-up (April to December 2018). Children's parents answered a questionnaire regarding sociodemographic information, FHS service, and dental service. Participants were clinically examined for dental caries. Multilevel Poisson regression was used to assess the associations between FHS variables at baseline and overall/domain-specific of the ECOHIS scores over time. A total of 365 children were reassessed for OHRQoL (follow-up rate: 79.5%). The absence of FHS coverage from the child's first year of age was associated with higher scores in the family function domain [rate ratio (RR) = 2.42; 95% confidence interval (CI) 1.28-4.58)]. Home visits by the FHS team members were associated with higher psychological domain scores (RR = 1.60; 95%CI 1.01-2.57). Children not covered by the FHS since the first year of age reported worse OHRQoL over time. This fact highlights the importance of an integrated health approach to promote children's health.

Previous studies have suggested that COVID-19 pneumonia is associated with an increased risk of venous thromboembolism (VTE). This study aimed to investigate the incidence of VTE among mechanically ventilated adults with COVID-19 pneumonia, compared to patients with respiratory failure related to other causes. Prospective study that enrolled critically ill adults with suspected COVID-19 pneumonia between June 2, 2020 and August 11, 2020. Critically ill adults with suspected COVID-19 pneumonia who required mechanical ventilation within 24 h after hospital admission were followed until death or hospital discharge. Sequential ultrasonography screening of the lower extremities and catheter insertion sites, as well as testing for plasma biochemical markers, were performed at the intensive care unit admission, day 3, day 7, and day 14. The primary outcome was a composite of deep venous thrombosis, pulmonary embolism, and thrombosis at the central catheter insertion sites. We enrolled 70 patients, including 57 patients with COVID-19 and 13 patients without COVID-19, and all patients completed follow-up. The incidence of the primary outcome was higher among patients with COVID-19 than among patients with respiratory failure related to other etiologies (36.8% vs. 0%, p = 0.023). Multivariate regression analysis revealed that VTE was independently associated with a COVID-19 diagnosis (odds ratio: 6.28, 95% confidence interval: 1.19-68.07) and D-dimer concentration (1-ng/mL increase, odds ratio: 1.15, 95% confidence interval: 1.05-1.30). The incidence of VTE was higher among critically ill mechanically ventilated patients, relative to among patients with respiratory failure related to other causes., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Aims and Objective: To identify clinical indicators of septic shock in critical care patients., Background: The identification of clinical indicators of septic shock is relevant to avoid clinical deterioration of patients with sepsis. However, the recognition of these factors, especially by the nursing team, is still deficient and reinforces the need for studies that investigate the subject in different realities such as that of Brazil., Design: The study had a cross-sectional design based on STROBE guidelines (see Appendix S1)., Methods: A sample of 392 patients with sepsis or septic shock was admitted to the Intensive Care Unit of a Brazilian university hospital. Data were collected from medical records of the Intrahospital Sepsis Combat Program referring to patients admitted between January 2018-January 2019. Sociodemographic and clinical data were collected, as well as information on the time from diagnosis of sepsis or septic shock to initiation of antibiotic therapy, length of stay, and discharge or death outcomes. Data were statically analysed., Results: Out of the total sample, 190 (49%) patients were admitted with septic shock. Clinical indicators of septic shock were hypotension, mechanical ventilation, lactate levels between 2.0-3.9 or >4, hypothermia <36°C, radiotherapy-associated chemotherapy, Sequential Organ Failure Assessment score >3 and admittance through the emergency unit. Among patients with septic shock, 85 (44.7%) were discharged and 105 (55.2%) died in the intensive care unit., Conclusions: Patients with septic shock presented hyperlactataemia and greater organic dysfunction as clinical indicators when compared to patients with sepsis. Mechanical ventilation, chemotherapy and radiotherapy increased the risk of developing septic shock., Relevance to Clinical Practice: Our results can support the nursing team by providing the main clinical indicators of septic shock and contributing to the interprofessional team in the prevention of septic shock., (© 2021 John Wiley & Sons Ltd.)

Background: Pacifier use is a major cause of anterior open bite (AOB), which negatively impacts the quality of life of children affected., Aim: To assess the direct and indirect pathways related to pacifier sucking habit and AOB in preschool children., Design: This 2-year cohort study evaluated a random sample of preschool children (2-5 years of age) from Southern Brazil. Caregivers answered a questionnaire addressing socio-economic and behavioural characteristics. Anterior open bite was recorded following the criteria recommended by Foster and Hamilton. Structural equation model was performed to assess the direct and indirect pathways among variables at baseline (T1) to predict the AOB at follow-up (T2)., Results: Regarding the AOB, 407 children were evaluated at T1 and 187 at T2. The prevalence of AOB was 32.9% at baseline and 16.0% at follow-up. The presence of AOB at follow-up was directly affected by the change in pacifier sucking habit from T1 to T2. Considering the indirect paths, the AOB at T1 influenced the AOB in T2 via a change of pacifier sucking habit., Conclusion: These findings suggest that the non-habit of sucking pacifiers is a fundamental strategy for the prevention of AOB as well as the promotion of health in childhood., (© 2020 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: To assess the relationship between time to focus clearance and hospital mortality in patients with sepsis and septic shock., Methods: This was an observational, single-center study with a retrospective analysis of the time to clearance of abdominal septic focus. Patients were classified according to the time to focus clearance into an early (≤ 12 hours) or delayed (> 12 hours) group., Results: A total of 135 patients were evaluated. There was no association between time to focus clearance and hospital mortality (≤ 12 hours versus > 12 hours): 52.3% versus 52.9%, with p = 0.137., Conclusion: There was no difference in hospital mortality among patients with sepsis or septic shock who had an infectious focus evacuated before or after 12 hours after the diagnosis of sepsis.

Background & Aims: Critically ill patients with body mass index (BMI) < 20 kg/m 2 have worse outcomes than normal/overweight patients possibly because underweight is a marker of malnutrition. To assess the effects of nutrition therapy in this population during the first week of an ICU stay., Methods: Prospective, 2-centre, observational study. Nutritional evaluations were performed between days 2 and 3 (first) and between days 5 and 7 (second) of ICU admission. In the first evaluation, patients were divided into non-fed (without nutritional support) and early-fed (those already receiving nutritional support) groups. In the second evaluation, patients were divided according to caloric intake (≥or<20 kcal/kg) and protein intake (≥or<1.3 g of protein/kg)., Results: Of the 4236 patients screened and 342 were included in the cohort. Mortality was 58.5% (median 21 [11-38.25] days of follow-up). Unadjusted patient survival was worse in the non-fed group than in the early-fed group (HR 1.66; 95%CI, 1.18 to 2.32). There was no difference in mortality between groups after adjusting for the SOFA score on the day of the evaluation. At the second evaluation, unadjusted analysis showed better in-hospital survival in patients with higher caloric (HR0.58; 95%CI, 0.40 to 0.86) and protein intake (HR0.59; 95%CI, 0.42 to 0.82); there was no association between mortality and caloric or protein intake after adjusting for the SOFA score on the day of the evaluation., Conclusion: Nutritional therapy in the first week of ICU stay did not affect vital outcome after adjusting for the SOFA score on the day of the evaluation in underweight critically ill patients., Clinical Trial Registry: ClinicalTrials.gov number NCT03398343., (Copyright © 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

The aim of this study was to evaluate the association of environmental and socioeconomic characteristics with the use of dental floss in preschool children. This cross-sectional study was conducted with a sample of 402 preschool children aged 1-5 years, from Santa Cruz do Sul, a Southern city in Brazil. Mothers answered questions about environmental, demographic, and socioeconomic characteristics. Behavior variables as use of dental floss (study outcome) and dental attendance were also evaluated. Poisson regression analysis with robust variance through a hierarchical approach was used to investigate the association of explanatory variables for use of dental floss. Prevalence ratio (PR) and 95% confidence intervals (95%CI) were estimated. The mean sample age was 3.32 years (standard deviation [SD] 1.10). Of the included children, 291 (73.12%) did not use dental floss. The environmental model indicated that children who attended daycare (PR 2.53; 95%CI 1.39-4.60) and those whose parents were members of volunteer networks (RP 1.58; 95%CI 1.02-2.46) were more likely to use dental floss. Children from families with higher income (PR 1.55; 95%CI 1.07-2.24) and maternal schooling (PR 2.21; 95%CI 1.31-3.74) presented a higher prevalence of dental floss use. Older children and those who attended dental services were also related to higher dental floss use. Our findings suggest that children who live in a supporting environment and those with a higher socioeconomic status are more likely to use dental floss.

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain., Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium., Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018., Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation., Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory)., Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation., Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium., Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.

Introduction: There is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest., Methods and Analysis: The study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor., Ethics and Dissemination: The institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals., Trial Registration Number: NCT03179020; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To systematically review the literature and synthesize evidence concerning the effects of vasopressin and its analogs compared with other vasopressors in distributive shock, focusing on renal outcomes., Data Sources: We performed a systematic review in MEDLINE, Embase, Cochrane Central, and Clinicaltrials.gov databases., Study Selection: Randomized clinical trials that compared vasopressin and its analogs with other vasopressors and reported renal outcomes in adult patients with distributive shock., Data Extraction: Paired reviewers independently screened citations, conducted data extraction and assessed risk of bias. Three prespecified subgroup analyses were conducted. Three main outcomes related to acute renal failure were analyzed: the need for renal replacement therapy, acute kidney injury incidence, and acute kidney injury-free days. I test was used to evaluate heterogeneity between studies. Substantial heterogeneity was defined as I greater than 50%. A random-effects model with Mantel-Haenszel weighting was used for all analyses. Heterogeneity was explored using subgroup analysis. The quality of evidence for intervention effects was summarized using Grading of Recommendations Assessment, Development, and Evaluation methodology. This study was registered in the PROSPERO database (CRD42017054324)., Data Synthesis: Three-thousand twenty-six potentially relevant studies were identified, and 30 articles were reviewed in full. Seventeen studies met the inclusion criteria, including a total of 2,833 individuals. Of these, 11 studies (2,691 individuals) were suitable for quantitative meta-analysis. Overall, the evidence was of low to moderate quality. Patients who received vasopressin and its analogs had a reduced need for renal replacement therapy (odds ratio, 0.59 [0.37-0.92]; p = 0.02; I = 49%) and a lower acute kidney injury incidence (odds ratio, 0.58 [0.37-0.92]; p = 0.02; I = 63%). These results should be interpreted with caution, due to excessive heterogeneity. Acute kidney injury-free data was not pooled, since the small number of studies and extreme heterogeneity., Conclusions: In patients with distributive shock, vasopressin and its analogs use is associated with a reduced need for renal replacement therapy and lower acute kidney injury incidence. These results are supported by high risk of bias evidence.

The long-lived polygynandrous ladybird beetle Tenuisvalvae notata (Mulsant) found in Brazil was evaluated in the laboratory for the effects of multiple mating and aging on its reproductive performance. This species is native to South America and is an important predator of mealybugs. Specifically studied were partner choice, female reproductive success, adult longevity, male virility, and offspring development. Young (5-10 days old) and older virgin females (95-100 days old) were subjected to either a single mate or multiple mating with the same or different males of various mating status (virgin or previously mated once, twice, and thrice). Results revealed a preference in both genders to mate with previously known partners. Additionally, younger females had higher fecundity and greater longevity when mated only once in comparison to those mated multiple times. Fecundity, fertility, and offspring development were similar across the treatments regardless of the number of mating or male mating history. Fecundity and fertility decreased throughout the oviposition period regardless of mating treatment.

Background: Vitamin D insufficiency is linked to several common inflammatory disorders. Brain death (BD) causes a massive catecholamine release, leading to intense inflammatory activity. We aimed to evaluate vitamin D serum levels in brain-dead individuals in comparison to critically ill patients without BD to assess the correlation between vitamin D and cytokine levels., Methods: Sixteen brain-dead patients and 32 critically ill controls were prospectively enrolled. Blood samples from 25 brain-dead patients from a previous study were also used for vitamin D quantification. Plasma TNF, IL-1β, IL-6, IL-8, IL-10, IFN-γ and serum vitamin D levels were compared using Student's t-test or one-way ANOVA. Spearman's test was used to assess the correlation between vitamin D and cytokine levels., Results: Mean vitamin D levels were 16.4 ± 7.9 ng/mL, with 52 patients (71.2%) classified as vitamin D deficient (serum levels < 20 ng/mL). Vitamin D levels were similar in 41 brain-dead patients as compared to control subjects (15.6 ± 6.9 ng/mL vs 17.4 ± 9.0 ng/mL; p = 0.383). Moderate direct correlations were observed between vitamin D and IL-8, IL-10, and IFN-γ in the prospective group of 16 brain-dead patients (IL-8: r = 0.5, p = 0.049; IL-10 r = 0.67, p = 0.005; IFN-γ r = 0.6, p = 0.015). Vitamin D was inversely correlated with IL-6 (r = -0.36, p = 0.044) in critically ill controls., Conclusions: Vitamin D serum levels were similarly low in brain-dead and critically ill patients. In brain-dead patients, vitamin D serum levels correlated with plasma IL-8, IL-10 and IFN-γ., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals., Methods and Analysis: A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals., Ethics and Dissemination: The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals., Trial Registration: NCT02932358., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: There is a need for a better understanding of the role of C-reactive protein (CRP) as a valid marker for the detection of bacterial infections in critically immunosuppressed patients. A high negative predictive value of CRP is also needed to rule out sepsis and bacterial infections in immunocompetent patients. However, few studies have evaluated the performance of CRP in immunocompromised hosts. The aim of the present study was to evaluate the performance of CRP as a marker of infection in critically immunosuppressed patients., Methods: The inclusion criterion was immunosuppression for which CRP was used as a bacterial infection marker. Searches were performed in the Cochrane Register, MEDLINE, EMBASE, SCOPUS, Web OF Science, LILACS and CINAHL databases. We applied the Quality Assessment of Diagnostic Accuracy Studies tool 2 (QUADAS 2) to evaluate the quality of the articles and evaluated the test accuracy parameters using hierarchical summary receiver operating characteristic (HSROC) curves and bivariate random effect models., Results: Only 13 of 21 studies produced quantitative results. We analyzed all studies using the random effects method (restricted maximum likelihood) and obtained a joint diagnostic odds ratio (DOR) of 3.04 (95% confidence interval [CI] 1.71-5.40) with heterogeneity (I 2 =91%, Q=181.48, p<0.001). Therefore, a bivariate model was applied. Analyzing the tuberculosis carrier, steroid user, or presence of opportunistic infection subgroups, as described in the proposal, was not possible due to the lack of information on these topics included in the articles., Conclusions: CRP appears to be a good screening tool for sepsis in critically immunosuppressed patients. Submitted PROSPERO 2015: CRD42015019329., (Copyright © 2017 Elsevier Inc. All rights reserved.)

We compared the discriminatory capacity of the sequential organ failure assessment (SOFA) versus the systemic inflammatory response syndrome (SIRS) score for predicting ICU mortality, need for and length of mechanical ventilation, ICU stay, and hospitalization in patients with suspected infection admitted to a mixed Brazilian ICU. We performed a retrospective analysis of a longitudinal ICU database from a tertiary hospital in Southern Brazil. Patients were categorized according to whether they met the criteria for sepsis according to SOFA (variation ≥2 points over the baseline clinical condition) and SIRS (SIRS score ≥2 points). From January 2008 to December 2014, 1487 patients were admitted to the ICU due to suspected infection. SOFA ≥2 identified more septic patients than SIRS ≥2 (79.0% [n=1175] vs. 68.5% [n=1020], p<0.001). There was no difference between the two scores in predicting ICU mortality (area under the receiver operating characteristic curve (AUROC)=0.64 vs. 0.64, p=0.99). SOFA ≥2 was marginally better than SIRS ≥2 in predicting need for mechanical ventilation (AUROC=0.64 vs. 0.62, p=0.001), ICU stay>7 days (AUROC=0.65 vs. 0.63, p=0.004), and length of hospitalization >10 days (AUROC=0.61 vs. 0.59, p<0.001). There was no difference between the two scores in predicting mechanical ventilation >7 days., (Copyright © 2017 Sociedade Brasileira de Infectologia. Published by Elsevier Editora Ltda. All rights reserved.)

Purpose: A comparative study of the use of the 2.0-mm locking fixation system with conventional systems in the treatment of mandibular fractures was performed., Methods: For this study, 87 consecutive patients with 112 mandibular fractures were randomized to receive either 2.0-mm locking plates (n = 45) or conventional 2.0- or 2.4-mm plates (n = 42) and had a minimum follow-up of 6 months. Fractures were classified based on the degree of displacement and complexity. Statistical analyses were used to verify possible differences between the groups when separately compared unfavourable and favourable cases (p ≤ 0.050)., Results: Despite randomization, systemic diseases were more frequent in the 2.0-mm locking group in favourable cases. Substance abuse occurred predominantly in the 2.0-mm locking group, in unfavourable and favourable fractures. There were more cases of complex fractures in the conventional group in unfavourable cases. One case involving a major postoperative complication occurred in the locking group (2.2%) and three cases occurred in the conventional group (7.1%) but with no significant difference between groups. In this study, there were no major differences between conventional and locking 2.0-mm locking systems with regard to the outcome of treated mandibular fractures, showing that both are adequate as long as the criteria of their indication and requirements for installation are met., Conclusions: It was concluded that the 2.0-mm locking fixation system can replace conventional systems in the treatment of mandibular fractures; in addition, this approach was effective in the treatment of unfavourable fractures that typically require the 2.4-mm conventional system.

Spontaneous breathing trials (SBTs) are among the most commonly employed techniques to facilitate weaning from mechanical ventilation. The preferred SBT technique, however, is still unclear. To clarify the preferable SBT (T-piece or pressure support ventilation [PSV]), we conducted this systematic review. We then searched the MEDLINE, EMBASE, SciELO, Google Scholar, CINAHL, ClinicalTrials.gov, and Cochrane CENTRAL databases through June 2015, without language restrictions. We included randomized controlled trials involving adult subjects being weaned from mechanical ventilation comparing T-piece with PSV and reporting (1) weaning failure, (2) re-intubation rate, (3) ICU mortality, or (4) weaning duration. Anticipating clinical heterogeneity among the included studies, we compared prespecified subgroups: (1) simple, difficult, or prolonged weaning and (2) subjects with COPD. We summarized the quality of evidence for intervention effects using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology. We identified 3,674 potentially relevant studies and reviewed 23 papers in full. Twelve studies (2,161 subjects) met our inclusion criteria. Overall, the evidence was of very low to low quality. SBT technique did not influence weaning success (risk ratio 1.23 [0.94-1.61]), ICU mortality (risk ratio 1.11 [0.80-1.54]), or re-intubation rate (risk ratio 1.21 [0.90-1.63]). Prespecified subgroup analysis suggested that PSV might be superior to T-piece with regard to weaning success for simple-to-wean subjects (risk ratio 1.44 [1.11-1.86]). For the prolonged-weaning subgroup, however, T-piece was associated with a shorter weaning duration (weighted mean difference -3.08 [-5.24 to -0.92] d). In conclusion, low-quality evidence is available concerning this topic. PSV may be associated with lower weaning failure rates in the simple-to-wean subgroup. In contrast, in prolonged-weaning subjects, T-piece may be related to a shorter weaning duration, although this is at high risk of bias. Further study of the difficult-to-wean and COPD subgroups is required., (Copyright © 2016 by Daedalus Enterprises.)

Objective: To evaluate the prevalence of antibiotic de-escalation in patients diagnosed with severe sepsis or septic shock at a public academic tertiary hospital and to evaluate antibiotic adequacy and culture positivity., Methods: The prevalence of antibiotic de-escalation, the adequacy of antibiotic treatment and the rates of culture positivity were analyzed in patients with severe sepsis and septic shock between April and December 2013 at an intensive care unit in a tertiary university hospital., Results: Among the 224 patients included in the study, de-escalation was appropriate in 66 patients (29.4%) but was implemented in 44 patients (19.6%). Among the patients who underwent de-escalation, half experienced narrowing of the antimicrobial spectrum. The mortality rate was 56.3%, with no differences between the patients with or without de-escalation (56.8% versus 56.1%; p = 0.999) nor in the length of hospital stay. Empirical antibiotic therapy was appropriate in 89% of cases. Microorganisms were isolated from total cultures in 30% of cases and from blood cultures in 26.3% of cases., Conclusion: The adequacy rate of empirical antibiotic therapy was high, reflecting an active institutional policy of monitoring epidemiological profiles and institutional protocols on antimicrobial use. However, antibiotic de-escalation could have been implemented in a greater number of patients. De-escalation did not affect mortality rates., Competing Interests: None

Objective: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients., Method: In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity., Results: Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity., Conclusions: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients.

Background: Phase angle (PA) is interpreted as an indicator of cell membrane integrity and a prognostic indicator in some clinical situations. This study aims to evaluate PA as a prognostic marker in critically ill patients admitted to the intensive care unit (ICU) and associate this marker with length of hospital stay, mortality, and clinical scores., Methods: A cohort study was conducted with 95 patients aged ≥18 years admitted to the ICU, who were assessed in terms of prognostic indexes (Acute Physiology and Chronic Health Evaluation II [APACHE II] and Sequential Organ Failure Assessment [SOFA]), clinical evolution (ICU discharge, death, and length of ICU stay), and PA., Results: Patients were predominantly male (63.1%) and had a mean age of 63.7 ± 14.6 years; length of stay of 4 days (range, 3-9 days); mortality of 15.8%; mean APACHE II and SOFA scores of 17.3 ± 8.2 and 6.1 ± 3.1 points, respectively; and mean PA of 4.91 ± 1.36°. An association was observed between females and PA <5.1° (P = .035), which was the cutoff point determined from the receiver operating characteristic curve. PA was correlated with APACHE II score (r = -0.241; P = .02). This correlation became moderate only when patients without sepsis were considered (r = -0.506; P < .001)., Conclusions: PA seems to be a good prognostic marker for patients without sepsis. The weak correlation between PA and APACHE II score and the lack of association with other clinical outcomes are limitations for interpreting the prognostic value of PA in the entire study sample., (© 2015 American Society for Parenteral and Enteral Nutrition.)

Introduction: Microsporidia constitute the most common black fly pathogens, although the species' diversity, seasonal occurrence and transmission mechanisms remain poorly understood. Infections by this agent are often chronic and non-lethal, but they can cause reduced fecundity and decreased longevity. The objective of this study was to identify microsporidia infecting Simulium (Chirostilbia) pertinax (Kollar, 1832) larvae from Caraguatatuba, State of São Paulo, Brazil, by molecular and morphological characterization., Methods: Larvae were collected at a single point in a stream in a rural area of the city and were kept under artificial aeration until analysis. Polydispyrenia spp. infection was characterized by the presence of at least 32 mononuclear spores measuring 6.9 ± 1.0 × 5.0 ± 0.7 µm in persistent sporophorous vesicles. Similarly, Amblyospora spp. were characterized by the presence of eight uninucleate spores measuring 4.5 × 3.5 µm in sporophorous vesicles., Results: The molecular analysis confirmed the presence of microsporidian DNA in the 8 samples (prevalence of 0.51%). Six samples (Brazilian larvae) were related to Polydispyrenia simulii and Caudospora palustris reference sequences but in separate clusters. One sample was clustered with Amblyospora spp. Edhazardia aedis was the positive control taxon., Conclusions: Samples identified as Polydispyrenia spp. and Amblyospora spp. were grouped with P. simulii and Amblyospora spp., respectively, corroborating previous results. However, the 16S gene tree showed a considerable distance between the black fly-infecting Amblyospora spp. and the mosquito-infecting spp. This distance suggests that these two groups are not congeneric. Additional genomic region evaluation is necessary to obtain a coherent phylogeny for this group.

Background: Obesity and diabetes mellitus are well-defined risk factors for cardiovascular mortality. The impact of antecedent hyperglycemia and body size on mortality in critical ill patients in intensive care units (ICUs) may vary across their range of values. Therefore, we prospectively analyzed the relationship between in-hospital mortality and preexisting hyperglycemia and body size in critically ill ICU patients to understand how mortality varied among normal, overweight, and obese patients and those with low, intermediate, and high glycated hemoglobin (HbA1c) levels., Methods: Medical history, weight, height, physiologic variables, and HbA1c were obtained during the first 24 h for patients who were consecutively admitted to the high complexity ICU of Hospital de Clínicas de Porto Alegre, Brazil, from April to August 2011. The relationships between mortality and obesity and antecedent hyperglycemia were prospectively analyzed by cubic spline analysis and a Cox proportional hazards model., Results: The study comprised 199 patients. The overall hospital mortality rate was 43.2% during a median 16 (8-28) days of follow-up. There was a progressive risk of in-hospital mortality with higher HbA1c levels, with the relationship becoming significant at HbA1c >9.3% compared with lower levels (hazard ratio 1.74; 95% confidence interval with Bonferroni correction 1.49-2.80). In contrast, mean body mass index (BMI) was higher in survivors than in nonsurvivors (27.2 kg/m2 ± 7.3 vs. 24.7 kg/m2 ± 5.0 P = 0.031, respectively). Cubic spline analysis showed that these relationships differed nonlinearly through the spectrum of BMI values. In a Cox proportional hazards model adjusted for Acute Physiology and Chronic Health Evaluation II score and HbA1c, the risk of in-hospital mortality progressively decreased with increasing BMI (BMI <20 vs. 20-23.9 kg/m2, P = 0.032; BMI <20 vs. 24-34.9 kg/m2, P = 0.010; BMI <20 vs. ≥35 kg/m2, P = 0.032)., Conclusions: Our findings suggest that significant hyperglycemia prior to ICU admission is a risk factor for in-hospital mortality. Conversely, increasing BMI may confer an advantageous effect against mortality in critical illness independently of previous glycemic control.

The production, distribution and use of electricity can generate low frequency electric and magnetic fields (50-60 Hz). Considering that some studies showed adverse effects on pancreatic β-cells exposed to these fields; the present study aimed to analyze the effects of 60 Hz electric fields on membrane potential during the silent and burst phases in pancreatic β-cells using a mathematical model. Sinusoidal 60 Hz electric fields with amplitude ranging from 0.5 to 4 mV were applied on pancreatic β-cells model. The sinusoidal electric field changed burst duration, inter-burst intervals (silent phase) and spike sizes. The parameters above presented dose-dependent response with the voltage amplitude applied. In conclusion, theoretical analyses showed that a 60 Hz electric field with low amplitudes changes the membrane potential in pancreatic β-cells.

Hyperglycemia is a commonly encountered issue in critically ill patients in the intensive care setting. The presence of hyperglycemia is associated with increased morbidity and mortality, regardless of the reason for admission (e.g., acute myocardial infarction, status post-cardiovascular surgery, stroke, sepsis). However, the pathophysiology and, in particular, the treatment of hyperglycemia in the critically ill patient remain controversial. In clinical practice, several aspects must be taken into account in the management of these patients, including blood glucose targets, history of diabetes mellitus, the route of nutrition (enteral or parenteral), and available monitoring equipment, which substantially increases the workload of providers involved in the patients' care. This review describes the epidemiology, pathophysiology, management, and monitoring of hyperglycemia in the critically ill adult patient.

Objective: To assess serum levels of the main factors that regulate the activation of the zona glomerulosa and aldosterone production in patients with septic shock, as well as their response to a high-dose (250 µg) adrenocorticotropic hormone (ACTH) stimulation test., Subjects and Methods: In 27 patients with septic shock, baseline levels of aldosterone, cortisol, ACTH, renin, sodium, potassium, and lactate were measured, followed by a cortrosyn test., Results: Renin correlated with baseline aldosterone and its variation after cortrosyn stimulation. Baseline cortisol and its variation did not correlate with ACTH. Only three patients had concomitant dysfunction of aldosterone and cortisol secretion., Conclusions: Activation of the zona glomerulosa and zona fasciculata are independent. Aldosterone secretion is dependent on the integrity of the renin-angiotensin-aldosterone system, whereas cortisol secretion does not appear to depend predominantly on the hypothalamic-pituitary-adrenal axis. These results suggest that activation of the adrenal gland in critically ill patients occurs by multiple mechanisms.

The purpose of this retrospective study was to evaluate contributing factors in patients requiring surgical retreatment of mandibular fractures. Of all the patients with mandibular fractures who were treated using internal fixation at a trauma hospital over a seven-year period, 20 patients (4.7%) required a second surgery and thus composed the "reoperated" group. The control group comprised 42 consecutive patients with mandibular fractures who were treated at the same clinic and who healed without complications. Medical charts were reviewed for gender, age, substance abuse history, dental condition, etiology, location of fracture, degree of fragmentation, fracture exposure, teeth in the fracture line, associated facial fractures, polytrauma, time elapsed between trauma and initial treatment, surgical approach and fixation system. Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) version 20.0; descriptive statistics and the chi-squared test were used to determine differences between groups. Significant differences in substance abuse (p = 0.006), dental condition (p < 0.001), location of fracture (p = 0.010), degree of fragmentation (p = 0.003) and fracture exposure (p < 0.001) were found. With regard to age and time elapsed between trauma and initial treatment, older patients (31.4 years, SD = 11.1) and a delay in fracture repair (19.1 days, SD = 18.7) were more likely to be associated with reoperation. It was concluded that substance abuse, age, dental condition, location of fracture, degree of fragmentation, fracture exposure and the time between trauma and initial treatment should be considered contributing factors to the occurrence of complications that require surgical retreatment of mandibular fractures.

Background: The shortage of organs is a limitation for transplantation, making the care of potential organ donors an important issue. The present systematic review and meta-analysis was carried out to assess the efficacy of interventions to stabilize hemodynamics in brain-dead donors or to improve organ function and outcomes of transplantation., Methods: Medline, Embase, and Cochrane databases were searched. Of 5096 articles retrieved, 39 randomized controlled trials were selected. Twenty were included in a qualitative synthesis, providing data on 1277 patients. The main interventions described were desmopressin use, triiodothyronine and methylprednisolone replacement, fluid management, vasopressor therapy, mechanical ventilation strategies, and surgical techniques., Results: Three meta-analyses were conducted: the first included two studies and showed that desmopressin administered to brain-dead patients was not advantageous with respect to early organ function in kidney recipients (relative risk, 0.97; 95% confidence interval [CI], 0.85-1.10; I(2) = 0%; P = 0.809). The second included four studies and showed that triiodothyronine did not add hemodynamic benefits versus standard management (weighted mean difference, 0.15; 95% CI, -0.13 to 0.42; I(2) = 17.4%; P = 0.304). The third meta-analysis (two studies) showed that ischemic liver preconditioning during harvesting procedures did not benefit survival (relative risk, 1.0; 95% CI, 0.93-1.08; I(2) = 0%; P = 0.459)., Conclusion: The present results suggest limited efficacy of interventions focusing on the management of brain-dead donors.

Objective: To calculate the values of the phase angle of septic patients using bioelectrical impedance analysis, correlate the values with clinical and biochemical variables, and compare them to reference values., Methods: Cohort study conducted with 50 septic patients aged ≥ 18 years old, admitted to intensive care units, and assessed according to prognostic indexes (APACHE II and SOFA), clinical progression (mortality, severity of sepsis, length of stay in intensive care unit), biochemical parameters (albumin and C-reactive protein), and the phase angle., Results: The average age of the sample was 65.6 ± 16.5 years. Most patients were male (58%) and suffering from septic shock (60%). The average APACHE II and SOFA scores were 22.98 ± 7.1 and 7.5 ± 3.4, respectively. The patients who survived stayed nine days on average (five to 13) in the intensive care unit, and the mortality rate was 30%. The average value of the phase angle was 5.4 ± 2.6° in the total sample and was smaller among the females compared with the males (p=0.01). The phase angle measures did not exhibit an association with the severity of the sepsis, mortality, gender, and age or correlate with the length of hospitalization or the biochemical parameters. The participants' phase angle values adjusted per gender and age were 1.1 to 1.9 times lower compared with the values for a normal population., Conclusion: The average value of the phase angle of septic patients was lower compared with the reference values for a healthy population. The phase angle measures did not exhibit association with the clinical and biochemical variables, which might be explained by the sample homogeneity.

Objective: Evaluate the compliance of septic patients' nutritional management with enteral nutrition guidelines for critically ill patients., Methods: Prospective cohort study with 92 septic patients, age ≥ 18 years, hospitalized in an intensive care unit, under enteral nutrition, evaluated according to enteral nutrition guidelines for critically ill patients, compliance with caloric and protein goals, and reasons for not starting enteral nutrition early or for discontinuing it. Prognostic scores, length of intensive care unit stay, clinical progression, and nutritional status were also analyzed., Results: The patients had a mean age of 63.4 ± 15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2 to 18.0) days, had 8.2 ± 4.2 SOFA and 24.1 ± 9.6 APACHE II scores, and had 39.1% mortality. Enteral nutrition was initiated early in 63% of patients. Approximately 50% met the caloric and protein goals on the third day of intensive care unit stay, a percentage that decreased to 30% at day 7. Reasons for the late start of enteral nutrition included gastrointestinal tract complications (35.3%) and hemodynamic instability (32.3%). Clinical procedures were the most frequent reason to discontinue enteral nutrition (44.1%). There was no association between compliance with the guidelines and nutritional status, length of intensive care unit stay, severity, or progression., Conclusion: Although the number of septic patients under early enteral nutrition was significant, caloric and protein goals at day 3 of intensive care unit stay were met by only half of them, a percentage that decreased at day 7.

This study analyzed the effects of unilateral detachment of the temporal muscle and coronoidotomy on facial growth in young rats. Thirty one-month-old Wistar rats were distributed into three groups: detachment, coronoidotomy and sham-operated. Under general anesthesia, unilateral detachment of the temporal muscle was performed for the detachment group, unilateral coronoidotomy was performed for the coronoidotomy group, and only surgical access was performed for the sham-operated group. The animals were sacrificed at three months of age. Their soft tissues were removed, and the mandible was disarticulated. Radiographic projections-axial views of the skulls and lateral views of hemimandibles-were taken. Cephalometric evaluations were performed, and the values obtained were submitted to statistical analyses. There was a significant homolateral difference in the length of the premaxilla, height of the mandibular ramus and body, and the length of the mandible in all three groups. However, comparisons among the groups revealed no significant differences between the detachment and coronoidotomy groups for most measurements. It was concluded that both experimental detachment of the temporal muscle and coronoidotomy during the growth period in rats induced asymmetry of the mandible and affected the premaxilla.

Introduction: Kaplan-Meier (KM) has become the most used method to evaluate time-to-event analysis, although it is unsuitable in competing event situations such as death and shock reversal. Despite that the use of this methodology is not widely disseminated, cumulative incidence analysis (CIA) is more appropriate in these situations. We used CIA and KM (with 2 different techniques of censoring) to compare shock reversal in a cohort of patients with septic shock after steroid therapy. Furthermore, we have analyzed shock reversal in responders and nonresponders to high-dose cortrosyn test (250 μg)., Methods: Analysis of shock reversal in a cohort of 74 patients with septic shock at a university hospital was done., Results: Shock reversal by the 28th day was estimated to be 88% and 72% by KM methods and 59% by CIA. In nonresponders to cortrosyn test (Δ ≤ 9 μg/dL), shock reversal was estimated in 80% and 56% according to KM and 47% according to CIA. As for responders to cortrosyn test, shock reversal was estimated in 90% and 77% according to KM and 64% according to the CIA method., Conclusion: Kaplan-Meier overestimates shock reversal. Cumulative incidence analysis seems to be a more appropriate method to analyze shock reversal. Future trials intended to analyze shock reversal should apply CIA., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Stress situations such as septic shock are accompanied by activation of the HPA axis. Some patients do not activate this axis in stress situations. This blunted response is currently designated as critical illness-related corticosteroid insufficiency (CIRCI). Currently the 250 μg cosyntropin stimulation test is the preferred diagnostic test for CIRCI. Few papers explored the role of the 1 μg cosyntropin test in septic shock patients. In this study, we compared both tests in septic shock patients taking a special interest in the population with intermediary baseline cortisol. Prospective noninterventional study included 74 septic shock patients. After measurement of baseline cortisol all patients received 1 μg of cosyntropin i. v. and 4 h later 249 μg of cosyntropin. We compared the cortisol increase after each test and its relation to mortality and vasopressor therapy. There was a moderate correlation in response to low and high dose cosyntropin, r(s)=0.55. This correlation in patients with baseline cortisol between 10-34 μg/dl is, r(s)=0.67. The increase induced by both tests was equally accurate to identify mortality and time of vasopressor withdrawal. Low and high dose cosyntropin tests presented a moderate correlation in patients with baseline cortisol between 10-34 μg/dl. Both tests are equally accurate to identify mortality and time of vasopressor therapy. These results suggest that both tests could be used to diagnose CIRCI., (© Georg Thieme Verlag KG Stuttgart · New York.)