[Simulation in healthcare during COVID-19: An experience with residents in Anaesthesiology]

BACKGROUND

The restrictions to stop COVID-19 pandemic have had a negative impact in simulation. However, it is imperative to develop new strategies that facilitate healthcare education.

OBJECTIVE

To describe a simulation in healthcare based on the learning of non-technical skills and performed under the restrictions of COVID-19 pandemic.

METHODS

Quasi-experimental study of an educational activity performed through simulation with Anaesthesiology residents in November 2020. Twelve residents participated in 2 consecutive days. A questionnaire was filled related to the performance of non-technical skills that encompasses leadership, teamwork and decision making. The complexity of the scenarios and the non-technical skills results obtained between the 2 days were analysed. Advantages and challenges were documented when a clinical simulation is performed under COVID-19 restrictions.

RESULTS

The global performance of the teams improved when comparing first and second day (79.5 vs. 88.6%, P < .01). Leadership was the worst section rated, however, was the one that showed the best improvement (70 vs. 87.5%, P < .01). The complexity of the simulation cases had no relation with the group performance in leadership and teamwork but affected task management results. General satisfaction was over 75%. The main challenges to develop the activity were the technology required to adapt virtuality to simulation and the time spent for the preparation of it. No cases of COVID-19 were reported within the first month after the activity.

CONCLUSION

Clinical simulation can be done in the context of COVID-19 pandemic, obtaining satisfactory learning results but requiring the adaptation of institutions to the new challenges it implies.

Simulation in healthcare during COVID-19: An experience with residents in Anaesthesiology

BACKGROUND

The restrictions to stop COVID-19 pandemic have had a negative impact in simulation, however, it is imperative to develop new strategies that facilitate healthcare education.

OBJECTIVE

To describe a simulation in healthcare based on the learning of Non-Technical Skills (NTS) and performed under the restrictions of COVID-19 Pandemic.

METHODS

Quasi-experimental study of an educational activity performed through simulation with anaesthesiology residents in November 2020. Twelve residents participated in two consecutive days. A questionnaire was filled related to the performance of NTS that encompasses leadership, teamwork and decision making. The complexity of the scenarios and the NTS results obtained between the two days were analysed. Advantages and challenges were documented when a clinical simulation is performed under COVID-19 restrictions.

RESULTS

The global performance of the teams improved when comparing first and second day (79.5% vs 88.6%, p<0.01). Leadership was the worst section rated, however, was the one that showed the best improvement (70% vs 87.5%, p<0.01). The complexity of the simulation cases had no relation with the group performance in leadership and teamwork but affected task management results. General satisfaction was over 75%. The main challenges to develop the activity were the technology required to adapt virtuality to simulation and the time spent for the preparation of it. No cases of COVID-19 were reported within the first month after the activity.

CONCLUSION

Clinical simulation can be done in the context of COVID-19 Pandemic, obtaining satisfactory learning results but requiring the adaptation of institutions to the new challenges it implies.

Potential association of Trypanosoma cruzi DTUs TcV and TcVI with the digestive form of Chagas disease

The relationship among genetic diversity of Trypanosoma cruzi and clinical forms of Chagas disease remain elusive. In order to assess the possible association between different T. cruzi Discrete Typing Units (DTUs) and the clinical pictures of the disease, 205 chronic patients from Salta province, Argentina, were analysed. One hundred and twenty-two of these patients were clinically categorized as: cardiac 38.5% (47/122), digestive 15% (18/122), cardio-digestive 16% (20/122) and asymptomatic 30% (37/122). From each patient, blood samples were taken for both, Polymerase Chain Reaction (PCR) targeting kDNA and blood culture analyses. The presence of T. cruzi kDNA was detected in 43% (88/205) of the patients. T. cruzi DTUs were identified in 74% (65/88) of the kDNA positive patients by PCR-hybridization using specific probes. We detected the presence of DTUs TcI, TcII, TcV and TcVI. Single infections (i.e. presence of only one DTU in the sample) were detected in 38.64% of the samples (34/88), while mixed infections were 35.23% (31/88). TcV was the most prevalent DTU (60.3%- 53/88). The association analyses showed, for the first time to the best of our knowledge, that TcV and TcVI were associated with the digestive form of Chagas Disease (Fisher p = .0001).

Basic Principles of Intraoperative Ultrasound Applied to Brain Tumor Surgery

Intraoperative ultrasound (US) has been shown to possess great value in assessing tumor volume and localization, especially for primary resection of gliomas and metastatic lesions. Given that US is a technology that is highly user dependent, many surgeons have encountered problems with the usage of this technology, as well as interpretation of intraoperative US images, limiting its full potential. This article focuses on the basic knowledge a neurosurgeon must acquire to properly use and interpret intraoperative US to improve tumor localization and extent of resection during brain tumor surgery.

Effectiveness of an intervention in multicomponent exercise in primary care to improve frailty parameters in patients over 70 years of age (MEFAP-project), a randomised clinical trial: rationale and study design

Background

Physical activity may reverse frailty in the elderly, but we encounter barriers to the implementation of exercise programs in this population. Our main aim is to evaluate the effect of a multicomponent physical activity program, versus regular medical practice, on reverting pre-frailty status among the elderly, 12 months post-intervention.

Methods

Randomized parallel group multicenter clinical trial located in primary care setting, among non-dependent and pre-frail patients > 70 years old, including 190 patients (95 intervention, 95 control group). Intervention: Multicomponent physical activity program (MEFAP, for its acronym in Spanish) with twelve 1.5 h-weekly sessions comprised of: 1. Informative session; 2. Exercises for improving aerobic resistance, muscle strength, propioception-balance and flexibility; and 3. Handing out of at-home exercise chart (twice/week). Main variable: pre-frailty according to the Fried phenotype. Secondary variables: sociodemographic, clinical and functional variables; exercise program adherence, patient satisfaction with the program and quality of life. We will perform an intention-to-treat analysis by comparing the retrogression from pre-frailty (1 or 2 Fried criteria) to robust status (0 Fried criteria) by the end of the intervention, 6 months and 12 months post-intervention. The accumulated incidence in each group will be calculated, as well as the relative risk (RR) and the number needed to treat (NNT) with their corresponding 95% confidence intervals. Protocol was approved by the Ethics Committee Hospital la Paz.

Discussion

Within the context of regular clinical practice, our results will provide evidence regarding the effects of exercise interventions on frailty among pre-frail older adults, a key population given their significant potential for functional, physical, and mental health improvement.

Trial registration

NCT03568084. Registered 26 June 2018. Date of enrollment of the first participant to the trial: July 2nd 2018.

Analysis of soluble or titanium dioxide derived titanium levels in human whole blood: consensus from an inter-laboratory comparison

Exposure to titanium (Ti),viathe ingestion of pigment grade Ti dioxide (TiO₂), is commonplace for westernised populations.

The caveolin-1 connection to cell death and survival

Caveolins are a family of membrane proteins required for the formation of small plasma membrane invaginations called caveolae that are implicated in cellular trafficking processes. In addition to this structural role, these scaffolding proteins modulate numerous intracellular signaling pathways; often via direct interaction with specific binding partners. Caveolin-1 is particularly well-studied in this respect and has been attributed a large variety of functions. Thus, Caveolin-1 also represents the best-characterized isoform of this family with respect to its participation in cancer. Rather strikingly, available evidence indicates that Caveolin-1 belongs to a select group of proteins that function, depending on the cellular settings, both as tumor suppressor and promoter of cellular traits commonly associated with enhanced malignant behavior, such as metastasis and multi-drug resistance. The mechanisms underlying such ambiguity in Caveolin-1 function constitute an area of great interest. Here, we will focus on discussing how Caveolin-1 modulates cell death and survival pathways and how this may contribute to a better understanding of the ambiguous role this protein plays in cancer.

Evaluation of the selective and differential ET medium for detection of Edwardsiella tarda in aquaculture systems

AIMS

Edwardsiella tarda is an important pathogen in aquaculture where it can cause serious losses. A rapid detection of it is vital to minimize the mortalities caused by this disease, and in this work, the effectiveness of the selective differential Edw. tarda medium (ET) was evaluated for the diagnosis of edwardsiellosis as well as for its possible use in epidemiological studies.

METHODS AND RESULTS

ET medium was evaluated in parallel with the commercial Salmonella-Shigella agar (SS), which is usually employed for the selective isolation of enteric bacilli. Moreover, two general media (TSA-1 and MA) were employed as a control. The results obtained showed that ET is distinctly selective for the isolation of Edw. tarda, allowing its recovery from mixed cultures and natural samples as a unique species. In contrast, although colonies of Edw. tarda could be clearly distinguishable in SS because of the appearance of a characteristic black centre, other enteric and nonenteric bacterial species were also able to grow on this medium.

CONCLUSIONS

We recommend ET agar as an useful medium for the primary isolation of Edw. tarda from aquaculture samples.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results obtained support ET medium as the most appropriate to develop epidemiological studies of edwardsiellosis in aquaculture and permits an earlier diagnosis of this important disease.

Acción del veneno de Bothrops diporus (yarará chica) del nordeste argentino sobre la hemostasia en diferentes mamíferos

<p>Los venenos de serpientes inducen gran variedad de efectos sobre la coagulación sanguínea debido a sus componentes coagulantes y anticoagulantes. En este trabajo se estudió el efecto del veneno de Bothrops diporus de Argentina sobre el sistema hemostático en diferentes especies de mamíferos, determinándose las actividades coagulante, fibrinolítica y letal. Se pudo comprobar que el veneno de esta serpiente genera desórdenes de la coagulación sanguínea atribuibles a enzimas de tipo trombinas que inducen la transformación del fibrinógeno a fibrina, registrándose mayor susceptibilidad en las especies ovina y humana. La dosis coagulante mínima se comparó con venenos de víboras centroamericanas, surgiendo que las serpientes de zonas más cálidas poseen menor actividad coagulante.</p>

Kinetics of isothermal degradation studies in adhesives by thermogravimetric data: effect of hydrophilic nanosilica fillers on the thermal properties of thermoplastic polyurethane-silica nanocomposites

The kinetics of thermal degradation process on thermoplastic polyurethanes (TPUs) adhesives with hydrophilic nanosilicas was studied using isothermal thermogravimetric analysis within the temperature range from 360 degrees C to 460 degrees C in nitrogen. The effect of nanosilicas with different hydrophilic degree in the thermoplastic polyurethanes was investigated. It was found that the thermoxidative degradation of polyurethane-silica nanocomposites takes place in one step. An analysis of the isothermal methods to evaluate kinetic parameters of decomposition of solids from isothermal thermogravimetric data is presented. Patents WO07146353A2 and US20070292623A1 have some relevant information about the topic develop in this study, because the principle in both cases relies on the interactions between reactive groups in the polymer (TPUs) and the silanol in the silica nano-particles.

Post-surgical follow-up (by ELISA and immunoblotting) of cured versus non-cured cystic echinococcosis in young patients

The study was designed to determine comparatively the prognostic value of immunoblotting and ELISA in the serological follow-up of young cystic echinococcosis (CE) patients exhibiting either a cured or a progredient (non-cured) course of disease after treatment. A total of 54 patients (mean age 9 years, range from 3 to 15 years) with surgically, radiologically and/or histologically proven CE were studied for a period up to 60 months after surgery. Additionally, some of the patients underwent chemotherapy. Based on the clinical course and outcome, as well as on imaging findings, patients were clustered into 2 groups of either cured (CCE), or non-cured (NCCE) CE patients. ELISA showed a high rate of seropositivity 4 to 5 years post-surgery for both CCE (57.1%) and NCCE (100%) patients, the difference found between the two groups was statistically not significant. Immunoblotting based upon recognition of AgB subcomponents (8 and 16 kDa bands) showed a decrease of respective antibody reactivities after 4 years post-surgery. Only sera from 14.3% of CCE patients recognized the subcomponents of AgB after 4 years, while none (0%) of these sera was still reactive at 5 years post-surgery. At variance, immunoblotting remained positive for AgB subcomponents in 100% of the NCCE cases as tested between 4 and 5 years after surgical treatment. Immunoblotting therefore proved to be a useful approach for monitoring post-surgical follow-ups of human CCE and NCCE in young patients when based upon the recognition of AgB subcomponents.

Improved serodiagnosis of alveolar echinococcosis of humans using an in vitro-produced Echinococcus multilocularis antigen

Serology is an important tool for the diagnosis of alveolar echinococcosis (AE) in humans. In order to improve serodiagnostic performance, we have developed an in vitro-produced Echinococcus mulilocularis metacestode vesicle fluid (EmVF) antigen for application in an immunoblot assay. Immunoblot analysis of EmVF revealed an abundant immunoreactive band triplet of 20-22 kDa, achieving a sensitivity of 100% based on the testing of sera from 62 pre-operative and pre-treatment cases of active and inactive AE. Thus, the EmVF-immunoblotting allowed the specific detection of cases seronegative by the Em2- and/or EmII/3-10-ELISA, usually attributable to abortive, inactive cases of AE. The specificity of the EmVF-immunoblotting did not allow discrimination between AE and cystic echinococcosis (CE) but was 100% with respect to non-Echinococcus parasitic infections or cancer malignancies. Based on the findings of this study, it is recommended that the current ELISA test combination (Em2- and II/3-10-ELISA) be complemented with EmVF-immunoblotting, allowing an improved diagnosis of both clinical and subclinical forms of AE, including those associated with E. multilocularis-specific antibody reactivities not detectable by ELISA.

Unscheduled returns to the emergency department: an outcome of medical errors?

BACKGROUND

The causes of unscheduled returns to the emergency department (ED) within 72 hours of discharge are unclear. A study was undertaken to identify factors associated with this quality care indicator.

METHODS

250 cases and 250 controls from the ED were prospectively studied. Outcomes measured were unscheduled returns, post-ED destination, and patient dissatisfaction. Possible medical errors (in diagnosis, treatment, prognosis or patient information) and errors in follow up care were identified. Other factors examined included chief complaint at presentation, discharge diagnosis, level of triage, category of treating physician, observation or not, application of emergency treatment, ancillary studies, accessibility to ED, ED time band or work shift, day of the week, past medical history, and demographic data (age, sex, educational level and economic status).

RESULTS

The main factor associated with unscheduled returns was error in prognosis (odds ratio 18.62, 95% CI 9.60 to 36.09). Advanced age and a chief complaint of dyspnoea were also associated with unscheduled returns and with admission to hospital. Post-ED destination worsened by 0.61 (95% CI 0.33 to 0.90) with diagnostic errors and by 0.60 (95% CI 0.30 to 0.90) with errors in follow up care. Patient dissatisfaction increased by 0.68 (95% CI 0.55 to 0.80) with information errors, by 0.63 (95% CI 0.17 to 1.09) with errors in follow up care, and by 0.52 (95% CI 0.09 to 0.94) with diagnostic errors.

CONCLUSION

Unscheduled returns are associated with medical errors in prognosis, treatment, follow up care, and information. A worse post-ED destination is associated with these medical errors and patient factors (dyspnoea and advanced age). Patient dissatisfaction is associated with medical errors, level of triage or care zone, patient educational level and ED time work shift. Most of these factors are modifiable.

Organotypic slice cultures from rat brain tissue: a new approach forNaegleria fowleriCNS infectionin vitro

The free-living amoebaNaegleria fowleriis the aetiological agent of primary amoebic meningoencephalitis (PAM), a disease leading to death in the vast majority of cases. In patients suffering from PAM, and in corresponding animal models, the brain undergoes a massive inflammatory response, followed by haemorrhage and severe tissue necrosis. Both,in vivoandin vitromodels are currently being used to study PAM infection. However, animal models may pose ethical issues, are dependent upon availability of specific infrastructural facilities, and are time-consuming and costly. Conversely, cell cultures lack the complex organ-specific morphology foundin vivo, and thus, findings obtainedin vitrodo not necessarily reflect the situationin vivo. The present study reports infection of organotypic slice cultures from rat brain withN. fowleriand compares the findings in this culture system within vivoinfection in a rat model of PAM, that proved complementary to that of mice. We found that brain morphology, as presentin vivo, is well retained in organotypic slice cultures, and that infection time-course including tissue damage parallels the observationsin vivoin the rat. Therefore, organotypic slice cultures from rat brain offer a newin vitroapproach to studyN. fowleriinfection in the context of PAM.

Diet and bladder cancer: a meta-analysis of six dietary variables

In 1996, more than 300,000 new cases of bladder cancer were diagnosed worldwide. Besides tobacco smoking, occupation, and other factors, diet may play a role in causation of this illness. The authors performed a meta-analytical review of epidemiologic studies linking six dietary factors to bladder cancer. These factors include retinol, beta-carotene, fruits, vegetables, meat, and fat. Increased risks of bladder cancer were associated with diets low in fruit intake (relative risk (RR) = 1.40, 95% confidence interval (CI): 1.08, 1.83), and slightly increased risks were associated with diets low in vegetable intake (RR = 1.16, 95% CI: 1.01, 1.34). Elevated risks were identified for diets high in fat intake (RR = 1.37, 95% CI: 1.16, 1.62) but not for diets high in meat intake (RR = 1.08, 95% CI: 0.82, 1.42). No increased risks were found for diets low in retinol (RR = 1.01, 95% CI: 0.83, 1.23) or beta-carotene (RR = 1.10, 95% CI: 0.93, 1.30) intake. These results suggest that a diet high in fruits and vegetables and low in fat intake may help prevent bladder cancer, but the individual dietary constituents that reduce the risks remain unknown.

Victims of violence in an emergency department

The aim of this study was to identify the risk profile of the victims of violent accidents. During 1997, we studied 1100 patients suffering from injuries produced by violent actions and treated in the emergency department of the largest teaching hospital in the Canary Islands, Spain. Seventy per cent of the patients were male and 30% were female. The mean age was 28 and 30 years, respectively. In the distribution by age, the main group was that between 18 and 36 years. Seventy-five per cent of violent accidents were public, 20% domestic and 5% remain unknown. The face-neck was the anatomical location with the highest number of severe injuries, followed by the upper extremities (42% vs. 26%, p<0.001). Eight per cent of the injured men presented severe injuries, in contrast with 1% of the women (p<0.001). Most patients (94%) were discharged from hospital after being treated. None of the victims died as a result of violence. The admission of victims occurred predominantly during the night hours and 35% of the patients were treated during the weekend. It is concluded that the typical victim of violent accidents in an emergency department of a Spanish teaching hospital is a young male with severe injuries, which occurred during late hours at weekends.

Comparison between mixed venous oxygen saturation and thermodilution cardiac output in monitoring patients with severe heart failure treated with milrinone and dobutamine

PURPOSE

Although thermodilution cardiac output (COtd) is the accepted method for monitoring patients with heart failure in the intensive care unit, it is particularly inaccurate in low-flow states and in the presence of tricuspid regurgitation; in addition, it does not adequately reflect the interaction between oxygen delivery and tissue oxygen extraction. We were concerned about the underuse of mixed venous oxygen saturation (SvO2) in this setting and hypothesized that it might be a more useful parameter than COtd for evaluating hemodynamic status and monitoring therapy in patients with severe congestive heart failure.

PATIENTS AND METHODS

We determined the correlation coefficients between increasing dose of inotrope and each of the parameters COtd and SvO2 in 18 patients with congestive heart failure who received a 3-day trial of either milrinone or dobutamine during admission to the Veterans Affairs Medical Center in San Diego. In addition, we analyzed reproducibility of repeated COtd and SvO2 measurements taken at a single dose of inotrope.

RESULTS

In patients receiving milrinone the increase in dose correlated much better with SvO2 (average correlation coefficient 0.79) than with COtd; this stronger correlation with SvO2 was seen in 82% of the trials reviewed (p < 0.05). In addition, we found that repeated SvO2 measurements taken at a single dose of milrinone were more reproducible than COtd as indicated by smaller relative 95% confidence intervals. In patients receiving dobutamine no significant trend in correlation coefficients or reproducibility was observed.

CONCLUSION

The knowledge that there is a significant relation between SvO2 and increasing dose of milrinone therapy in patients with severe heart failure and tricuspid regurgitation has practical value for physicians monitoring these patients in the intensive care unit. We believe this study demonstrates the worth of SvO2 in detecting hemodynamic change during trials of milrinone therapy and that this parameter may in fact be more reproducible than traditional thermodilution methods.

Host range susceptibility of Enterococcus sp. strains isolated from diseased turbot: possible routes of infection

Experiments were conducted to assess the pathogenicity of Enterococcus sp. strains isolated from diseased turbot for several fish species (turbot, salmon, trout, and seabream), as well as for mice. The intraperitoneal injection assays indicated that the tested strains showed host specificity for turbot, with a high degree of virulence (50% lethal dose of 10(4) cells per g of fish). The Spanish Enterococcus sp. isolates were nonpathogenic for the other fish species studied and for mice. The possible routes of infection were determined by bath exposure (with and without prior abrasion of the skin) and by intragastric inoculations with food and feces contaminated with the pathogen. The bath challenges indicated that the Enterococcus isolates were able to overcome the defense mechanisms present on the surface of the turbot only if the skin was abraded prior to the exposure. The antibacterial activities of components of a glycoprotein nature present in the turbot skin mucus are probably responsible in part for the resistance in noninjured fish to infection. On the other hand, we demonstrated the capacity of this pathogen to overcome adverse conditions in the stomachs of fish when associated with food or fecal material, since it is able to establish an infective state and to produce mortalities after 16 to 20 days postingestion. From all of these findings, we can conclude that horizontal transmissions through water and the fecal-oral route are the main avenues of infection of turbot streptococcosis.