Effect of growth rates on hormonal and pubertal status in Nellore heifers early weaned

This study aimed to determine the effect of growth rates on the hormonal status and puberty onset. Forty-eight Nellore heifers were weaned at 3.0 ± 0.1 (means ± standard error of the mean) months old were blocked according to body weight at weaning (84 ± 2 kg) and randomly assigned to treatments. The treatments were arranged in 2 × 2 factorial according to the feeding program. The first program was high (H; 0.79 kg/day) or control (C; 0.45 kg/day) average daily gain (ADG) from 3^rd to 7^th month of age (growing phase I). The second program was also high (H; 0.70 kg/day) or control (C; 0.50 kg/day) ADG from the 7^th month until puberty (growing phase II), resulting in four treatments: HH (n = 13), HC (n = 10), CH (n = 13), and CC (n = 12). To achieve desired gains, heifers in high ADG program were fed ad libitum dry matter intake (DMI), and the control group was offered around 50% of ad libitum DMI of high group. All heifers received a diet with similar composition. Puberty was assessed weekly by ultrasound examination, and the largest follicle diameter was evaluated every month. Blood samples were collected to quantify leptin, insulin growth factor-1 (IGF1) and luteinizing hormone (LH). At 7 months of age, heifers in high ADG were 35 kg heavier than the control. Heifers in the HH had greater DMI compared with CH in phase II. The puberty rate at 19 months old was greater in the HH treatment (84%) than in the CC (23%), but there was no difference between HC (60%) and CH (50%) treatments. Heifers from HH treatment had greater serum leptin concentration than others at 13 months old, and serum leptin was greater in HH compared with CH and CC at 18 months old. High heifers in phase I had greater serum IGF1 concentration than the control. In addition, HH heifers had a greater diameter of the largest follicle than CC. There was no interaction between phases and age in any variable relative to the LH profile. However, the heifers' age was the main factor that increased the frequency of LH pulse. In conclusion, increasing ADG was associated with greater ADG, serum leptin and IGF-1 concentration, and puberty onset; however, LH concentration was affected mainly by age of the animal. The increasing growth rate at younger age made heifers more efficient.

Determinants of death in critically ill COVID-19 patients during the first wave of COVID-19: a multicenter study in Brazil

OBJECTIVE

To evaluate clinical outcomes and factors associated with mortality, focusing on secondary infections, in critically ill patients with COVID-19 in three Brazilian hospitals during the first pandemic wave.

METHODS

This was a retrospective observational study involving adult patients with COVID-19 admitted to one of the participating ICUs between March and August of 2020. We analyzed clinical features, comorbidities, source of SARS-CoV-2 infection, laboratory data, microbiology data, complications, and causes of death. We assessed factors associated with in-hospital mortality using logistic regression models.

RESULTS

We included 645 patients with a mean age of 61.4 years. Of those, 387 (60.0%) were male, 12.9% (83/643) had undergone solid organ transplant, and almost 10% (59/641) had nosocomial COVID-19 infection. During ICU stay, 359/644 patients (55.7%) required invasive mechanical ventilation, 225 (34.9%) needed renal replacement therapy, 337 (52.2%) received vasopressors, and 216 (33.5%) had hospital-acquired infections (HAIs), mainly caused by multidrug-resistant gram-negative bacteria. HAIs were independently associated with a higher risk of death. The major causes of death were refractory shock and multiple organ dysfunction syndrome but not ARDS, as previously reported in the literature.

CONCLUSIONS

In this study, most of our cohort required invasive mechanical ventilation and almost one third had HAIs, which were independently associated with a higher risk of death. Other factors related to death were Charlson Comorbidity Index, SOFA score at admission, and clinical complications during ICU stay. Nosocomial COVID-19 infection was not associated with death. The main immediate causes of death were refractory shock and multiple organ dysfunction syndrome.

Implications of growth rates and compensatory growth on puberty attainment in Nellore heifers

This study investigated the effects of growth rates and compensatory growth on puberty attainment in Nellore heifers. Nellore heifers (n = 120), weaned at 8 ± 0.75 mo of age, were blocked by sire and BW (180 ± 8.6 kg) and assigned randomly to receive 1 of 4 treatments over a 10-mo period. Treatments included ad libitum feeding (high gain, HG), feed intake to gain 0.6 kg/d (medium gain, MG), restricted feeding (0.2 kg/d) for 4 mo followed by ad libitum feeding for 6 mo (compensatory gain, CG), and alternating periods of ad libitum and restricted feeding for 2 mo each throughout the trial (alternated CG, ACG). Puberty was assessed weekly by transrectal ultrasonography. Blood samples were collected at 8, 11, and 18 mo of age and at puberty to determine circulating concentrations of leptin. At 18 mo of age, nonpubertal heifers were treated with a puberty induction protocol using an intravaginal progestin device. There was no treatment effect (P = 0.17) on the percentage of heifers pubertal by 18 mo of age (HG: 66, MG: 40, CG: 58, and ACG: 52%), BW at puberty, and age at puberty. However, HG heifers had higher ADG (P < 0.01), dry matter intake (P < 0.01), and leptin concentrations (P = 0.03) than heifers from other groups. The response to the puberty induction protocol was similar (P = 0.90) among treatments. Regarding sire effects (genetic effects), there was an effect (P = 0.03) on the percentage of heifers pubertal by 18 mo of age and a tendency (P = 0.07) of sire effect in response to the puberty induction protocol. Compensatory growth appears to be an effective managerial approach to decrease feeding costs and stimulate puberty in Nellore heifers.

Availability of resources to treat sepsis in Brazil: a random sample of Brazilian institutions

OBJECTIVE

To characterize resource availability from a nationally representative random sample of intensive care units in Brazil.

METHODS

A structured online survey of participating units in the Sepsis PREvalence Assessment Database (SPREAD) study, a nationwide 1-day point prevalence survey to assess the burden of sepsis in Brazil, was sent to the medical director of each unit.

RESULTS

A representative sample of 277 of the 317 invited units responded to the resources survey. Most of the hospitals had fewer than 500 beds (94.6%) with a median of 14 beds in the intensive care unit. Providing care for public-insured patients was the main source of income in two-thirds of the surveyed units. Own microbiology laboratory was not available for 26.8% of the surveyed intensive care units, and 10.5% did not always have access to blood cultures. Broad spectrum antibiotics were not always available in 10.5% of surveyed units, and 21.3% could not always measure lactate within three hours. Those institutions with a high resource availability (158 units, 57%) were usually larger and preferentially served patients from the private health system compared to institutions without high resource availability. Otherwise, those without high resource availability did not always have broad-spectrum antibiotics (24.4%), vasopressors (4.2%) or crystalloids (7.6%).

CONCLUSION

Our study indicates that a relevant number of units cannot perform basic monitoring and therapeutic interventions in septic patients. Our results highlight major opportunities for improvement to adhere to simple but effective interventions in Brazil.

Implementation of sepsis bundles in public hospitals in Brazil: a prospective study with heterogeneous results

Background

Public hospitals in emerging countries pose a challenge to quality improvement initiatives in sepsis. Our objective was to evaluate the results of a quality improvement initiative in sepsis in a network of public institutions and to assess potential differences between institutions that did or did not achieve a reduction in mortality.

Methods

We conducted a prospective study of patients with sepsis or septic shock. We collected baseline data on compliance with the Surviving Sepsis Campaign 6-h bundles and mortality. Afterward, we initiated a multifaceted quality improvement initiative for patients with sepsis or septic shock in all hospital sectors. The primary outcome was hospital mortality over time. The secondary outcomes were the time to sepsis diagnosis and compliance with the entire 6-h bundles throughout the intervention. We defined successful institutions as those where the mortality rates decreased significantly over time, using a logistic regression model. We analyzed differences over time in the secondary outcomes by comparing the successful institutions with the nonsuccessful ones. We assessed the predictors of in-hospital mortality using logistic regression models. All tests were two-sided, and a p value less than 0.05 indicated statistical significance.

Results

We included 3435 patients from the emergency departments (50.7%), wards (34.1%), and intensive care units (15.2%) of 9 institutions. Throughout the intervention, there was an overall reduction in the risk of death, in the proportion of septic shock, and the time to sepsis diagnosis, as well as an improvement in compliance with the 6-h bundle. The time to sepsis diagnosis, but not the compliance with bundles, was associated with a reduction in the risk of death. However, there was a significant reduction in mortality in only two institutions. The reduction in the time to sepsis diagnosis was greater in the successful institutions. By contrast, the nonsuccessful sites had a greater increase in compliance with the 6-h bundle.

Conclusions

Quality improvement initiatives reduced sepsis mortality in public Brazilian institutions, although not in all of them. Early recognition seems to be a more relevant factor than compliance with the 6-h bundle.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1858-z) contains supplementary material, which is available to authorized users.

Crude glycerin decreases nonesterified fatty acid concentration in ewes during late gestation and early lactation

Crude glycerin is a gluconeogenic substrate in ruminants and may help to decrease the occurrence of pregnancy toxemia. The objective in this trial was to determine the effects of feeding a diet containing crude glycerin on DMI, milk yield, milk composition, and blood metabolites in periparturient ewes and lamb performance. One hundred eighteen 90 (±1.1)-d pregnant Santa Inês ewes were used. After lambing, 32 ewes (62.8 ± 1.3 kg BW) were allotted in a randomized complete block design defined by prelambing diet, BW, BCS, lambing date, type of birth (single or twin), and sex of offspring. Diets were isonitrogenous (13.0 ± 0.3% CP, DM basis), composed of concentrate and raw sugarcane bagasse (70:30 ratio, DM basis), and fed ad libitum daily. Crude glycerin (83.6% glycerol) levels were 0 or 10% (DM basis), corresponding to the experimental diets G0 and G10, respectively. From 8 until 56 d of lactation, DMI was determined. In the same period, once a week at 1000 h, the ewes were separated from the lambs and mechanically milked after intravenous administration of 10 IU of synthetic oxytocin. Three hours after the first milking, ewes were milked again and milk yield and composition were determined. Glucose, NEFA, and β-hydroxybutyrate (BHBA) were determined at -14, -7, 0, 7, 14, 28, and 56 d relative to lambing and insulin was determined at -14, -7, 0, and 7 d. Crude glycerin did not affect DMI (2.2 kg/d for G0 vs. 2.2 kg/d for G10; = 0.93) or milk production (171 g/3 h for G0 vs. 164 g/3 h for G10; = 0.66). However, there was a decrease ( = 0.01) in milk fat percentage (8.1% for G0 vs. 7.0% for G10) for ewes fed glycerin. Ewes fed the G10 diet had decreased ( < 0.01) NEFA concentration (0.27 mmol/L for G0 vs. 0.18 mmol/L for G10). There was an interaction between diet × time for glucose ( = 0.04), insulin ( = 0.05), and BHBA ( = 0.01); feeding glycerin increased glucose (5.61 mmol/L for G0 vs. 7.42 mmol/L for G10; < 0.01) and insulin concentrations (10.5 μIU for G0 vs. 24.5 μIU for G10; < 0.01) at parturition compared with G0. The BHBA was less ( = 0.02) on the day of lambing (0.40 mmol/L for G0 vs. 0.29 mmol/L for G10) and it was greater ( < 0.01) on d 56 for ewes fed the G10 diet (0.46 mmol/L for G0 vs. 0.61 mmol/L for G10). There was no effect of diets fed to ewes on lamb growth from birth to weaning. Crude glycerin improved energy balance of periparturient ewes, suggesting a reduced risk of developing clinical metabolic-related disorders. Crude glycerin can be added at 10% of ewes' diets without affecting DMI and milk yield.

Daily laxative therapy reduces organ dysfunction in mechanically ventilated patients: a phase II randomized controlled trial

INTRODUCTION

Constipation is a common problem in intensive care units. We assessed the efficacy and safety of laxative therapy aiming to promote daily defecation in reducing organ dysfunction in mechanically ventilated patients.

METHODS

We conducted a prospective, randomized, controlled, nonblinded phase II clinical trial at two general intensive care units. Patients expected to remain ventilated for over 3 days were randomly assigned to daily defecation or control groups. The intervention group received lactulose and enemas to produce 1-2 defecations per day. In the control group, absence of defecation was tolerated up to 5 days. Primary outcome was the change in Sequential Organ Failure Assessment (SOFA) score between the date of enrollment and intensive care unit discharge, death or day 14.

RESULTS

We included 88 patients. Patients in the treatment group had a higher number of defecations per day (1.3 ± 0.42 versus 0.7 ± 0.56, p < 0.0001) and lower percentage of days without defecation (33.1 ± 15.7% versus 62.3 ± 24.5%, p < 0.0001). Patients in the intervention group had a greater reduction in SOFA score (-4.0 (-6.0 to 0) versus -1.0 (-4.0 to 1.0), p = 0.036) with no difference in mortality rates or in survival time. Adverse events were more frequent in the treatment group (4.5 (3.0-8.0) versus 3.0 (1.0-5.7), p = 0.016), including more days with diarrhea (2.0 (1.0-4.0) versus 1.0 (0-2.0) days, p < 0.0001). Serious adverse events were rare and did not significantly differ between groups.

CONCLUSIONS

Laxative therapy improved daily defecation in ventilated patients and was associated with a greater reduction in SOFA score.

TRIAL REGISTRATION

Clinical Trials.gov NCT01607060, registered 24 May 2012.

Reclassifying the spectrum of septic patients using lactate: severe sepsis, cryptic shock, vasoplegic shock and dysoxic shock

Objective

The current definition of severe sepsis and septic shock includes a heterogeneous profile of patients. Although the prognostic value of hyperlactatemia is well established, hyperlactatemia is observed in patients with and without shock. The present study aimed to compare the prognosis of septic patients by stratifying them according to two factors: hyperlactatemia and persistent hypotension.

Methods

The present study is a secondary analysis of an observational study conducted in ten hospitals in Brazil (Rede Amil - SP). Septic patients with initial lactate measurements in the first 6 hours of diagnosis were included and divided into 4 groups according to hyperlactatemia (lactate >4mmol/L) and persistent hypotension: (1) severe sepsis (without both criteria); (2) cryptic shock (hyperlactatemia without persistent hypotension); (3) vasoplegic shock (persistent hypotension without hyperlactatemia); and (4) dysoxic shock (both criteria).

Results

In total, 1,948 patients were analyzed, and the sepsis group represented 52% of the patients, followed by 28% with vasoplegic shock, 12% with dysoxic shock and 8% with cryptic shock. Survival at 28 days differed among the groups (p<0.001). Survival was highest among the severe sepsis group (69%, p<0.001 versus others), similar in the cryptic and vasoplegic shock groups (53%, p=0.39), and lowest in the dysoxic shock group (38%, p<0.001 versus others). In the adjusted analysis, the survival at 28 days remained different among the groups (p<0.001) and the dysoxic shock group exhibited the highest hazard ratio (HR=2.99, 95%CI 2.21-4.05).

Conclusion

The definition of sepsis includes four different profiles if we consider the presence of hyperlactatemia. Further studies are needed to better characterize septic patients, to understand the etiology and to design adequate targeted treatments.

Growth, feed intake, carcass characteristics, and eating behavior of feedlot lambs fed high-concentrate diets containing soybean hulls

The objectives of this experiment were to determine the effects of replacing ground corn with soybean hulls (SH) in high-concentrate diets on the growth (56-d period), carcass characteristics, and eating behavior of feedlot lambs. Sixty-four Santa Inês ram lambs (18.3 ± 2.8 kg of BW and 69 ± 5 d of age) were assigned to a randomized complete block design experiment with 8 blocks and 4 diets. The control diet contained 10% coastcross (Cynodon sp.) hay, 70% corn, and no SH (SH0) in the dietary DM. In the remaining diets, SH replaced corn at the rate of 15 (SH15), 30 (SH30), or 45% (SH45) of the original corn concentration, resulting in 0, 10.5, 21.0, or 31.4% SH in the dietary DM. Dry matter intake increased linearly (P < 0.01) when SH replaced ground corn (1.0, 1.0, 1.1, and 1.1 kg/d for SH0, SH15, SH30, and SH45, respectively). There was no effect on ADG of lambs, with values of 276, 278, 282, and 287 g for SH0, SH15, SH30, and SH45, respectively. Feed efficiency decreased linearly (P < 0.01) with SH inclusion. Carcass measures were not affected by SH as a replacement for ground corn. Eating time, expressed as minutes per day and minutes per gram of NDF, showed a quadratic effect (P < 0.05), whereas no effect was observed when expressed as minutes per gram of DM. Rumination, in minutes per day, was not influenced by dietary SH inclusion, but a linear decrease (P < 0.01) was observed when this variable was expressed as minutes per gram of NDF. Soybean hulls can replace up to 45% of the ground corn (31.4% of SH in the dietary DM) in high-concentrate diets fed to feedlot lambs without negative effects on ADG and carcass measures. The linear decrease in feed efficiency (11.6% reduction from SH0 to SH45) suggests that optimal dietary SH inclusion rates should be dictated by the relative costs of SH and corn.

Apparent digestibility, nitrogen balance, and ruminal constituents in ram lambs fed high-concentrate diets containing soybean hulls

Corn often constitutes the main portion of high-concentrate diets fed to feedlot lambs. However, soybean hulls (SH) may be used to replace corn, and may reduce feed costs and the risk of acidosis. The objective of this experiment was to determine the effect of SH inclusion rate in high-concentrate diets on DMI, apparent digestibility of nutrients, N balance, and some rumen constituents. Sixteen ruminally fistulated Santa Inês ram lambs (44.3 ± 5 kg of BW and 6 mo old) were housed in suspended metabolism crates. A randomized complete block design experiment with 4 diets and 4 blocks was used. Blocks were defined by BW, and diets were allotted randomly within block. The control diet contained 70% corn and 0% SH. In the remaining diets, SH replaced corn at the rate of 15, 30, or 45% of the original corn concentration, which resulted in 0, 10.5, 21.0, and 31.4% of SH in the dietary DM. The DMI (kg/d) increased linearly (P < 0.01) with increasing dietary SH inclusion. A trend was observed for linear decreases (P = 0.10) in apparent DM, OM, and nonfiber carbohydrate digestibility, and a trend was observed for an increase (P = 0.08) in NDF digestibility with increasing dietary SH addition. Apparent digestibilities of CP and ether extract and ADF digestibility were not affected by SH inclusion rate. Total ruminal concentration of short-chain fatty acids was affected quadratically (P = 0.03) by diet; acetate concentration increased linearly (P < 0.01), whereas quadratic effects were observed on propionate concentration (P = 0.03) and acetate-to-propionate ratio (P < 0.01) with increasing dietary SH. Ruminal pH increased linearly (P < 0.01) as corn was replaced by SH. Nitrogen retention was not affected by the addition of SH, in spite of a linear increase in urinary N (P < 0.01). The replacement of corn grain with up to 45% SH (31.4% of SH in the dietary DM) resulted in a trend to decrease apparent digestibility of DM and to increase NDF digestibility, presenting a fermentation pattern that would reduce the risk of acidosis.

Prazer e sofrimento no processo de trabalho do enfermeiro docente

Trata-se de um estudo exploratório e descritivo com abordagem qualitativa, que compreende sentimentos que perpassam o processo de trabalho do enfermeiro em três universidades privadas do Município de São Paulo, revelando-se experiências enriquecedoras de significados do saber-fazer na prática docente. Assim, a presente investigação tem como objetivo identificar os aspectos geradores de prazer e de sofrimento no processo de trabalho do enfermeiro docente, analisados segundo o referencial teórico de Christophe Dejours, pontuando-se a importância de fatores psicossociais em relação ao objeto estudado. Os resultados da investigação apontam para as relações ambíguas presentes no processo de trabalho dos docentes, expressando sentimentos de prazer e sofrimento decorrentes dessa prática e evidenciando as condições e a organização do trabalho como elementos que podem potencializar tais sentimentos no cotidiano do trabalho do enfermeiro naquelas instituições.

Intestinal constipation in intensive care units

Constipation is a common complication identified among critically ill patients. Its incidence is highly variable due to lack of definition of such patients. Besides the already known consequences of constipation, in recent years it was observed that this complication may also be related to worse prognosis of critically ill patients. This review endeavors to describe the main available scientific evidence showing that constipation is a prognostic marker and a clinical representation of intestinal dysfunction, in addition to eventually interfering in the prognosis with treatment. Ogilvie syndrome, a major cause of morbidity and mortality in intensive care units was also reviewed. Considering the above cases it was concluded that more attention to this disorder is required in intensive care units as well as development of protocols for diagnosis and management of critically ill patients.

[Professional satisfaction of the nurse professor: a qualitative study]

The aim of this study was to recognize the satisfaction of the nurse professor of the nursing graduation course and to identify factors which, according to the professors, interfere in this state of satisfaction. Semi-structured interviews were performed with eight nurse professors from an official nursing school in the city of São Paulo. The results were analyzed according to the plan of the content analysis proposed by Bardin, under a qualitative approach. The results showed that they feel satisfied regarding their labor activities and the positive or negative influential feeling of satisfaction of the professors coincide and have a relation with the student, the teaching institution and the professors themselves. Evidence of the important influence of the teaching period of service and the trajectory of the professor formation suggest the need of new studies related to these factors.

Respiratory muscle unloading improves leg muscle oxygenation during exercise in patients with COPD

BACKGROUND

Respiratory muscle unloading during exercise could improve locomotor muscle oxygenation by increasing oxygen delivery (higher cardiac output and/or arterial oxygen content) in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Sixteen non-hypoxaemic men (forced expiratory volume in 1 s 42.2 (13.9)% predicted) undertook, on different days, two constant work rate (70-80% peak) exercise tests receiving proportional assisted ventilation (PAV) or sham ventilation. Relative changes (Delta%) in deoxyhaemoglobin (HHb), oxyhaemoglobin (O(2)Hb), tissue oxygenation index (TOI) and total haemoglobin (Hb(tot)) in the vastus lateralis muscle were measured by near-infrared spectroscopy. In order to estimate oxygen delivery (Do(2)est, l/min), cardiac output and oxygen saturation (Spo(2)) were continuously monitored by impedance cardiography and pulse oximetry, respectively.

RESULTS

Exercise tolerance (Tlim) and oxygen uptake were increased with PAV compared with sham ventilation. In contrast, end-exercise blood lactate/Tlim and leg effort/Tlim ratios were lower with PAV (p<0.05). There were no between-treatment differences in cardiac output and Spo(2) either at submaximal exercise or at Tlim (ie, Do(2)est remained unchanged with PAV; p>0.05). Leg muscle oxygenation, however, was significantly enhanced with PAV as the exercise-related decrease in Delta(O(2)Hb)% was lessened and TOI was improved; moreover, Delta(Hb(tot))%, an index of local blood volume, was increased compared with sham ventilation (p<0.01).

CONCLUSIONS

Respiratory muscle unloading during high-intensity exercise can improve peripheral muscle oxygenation despite unaltered systemic Do(2 )in patients with advanced COPD. These findings might indicate that a fraction of the available cardiac output had been redirected from ventilatory to appendicular muscles as a consequence of respiratory muscle unloading.