Efetividade das dietas enriquecidas com imunonutrientes na redução de complicações e mortalidade em pacientes críticos: abordagem pela utilização de metanálise

Nutrientes específicos, denominados farmaconutrientes, demonstraram possuir a capacidade de modular a resposta imunológica e inflamatória de animais e seres humanos, em estudos clínicos e laboratoriais. Dentre os substratos conhecidos, os que têm maior relevância e ação imunomoduladora são a arginina, glutamina, ácido graxo n-3 e nucleotídeos. No entanto, revisões sistemáticas e meta-análises buscam consenso em relação aos vários e controversos resultados publicados sobre os possíveis benefícios da imunonutrição em pacientes críticos. Nossos objetivos foram avaliar a efetividade das dietas enriquecidas com Imunonutrientes na redução de complicações e mortalidade nos diferentes tipos de pacientes críticos. O presente estudo é uma revisão sistemática com metanálise onde foram inseridos ensaios clínicos randomizados avaliando o uso de nutrientes imunomoduladores em doente adulto de ambos os sexos, definido como crítico traumatizado, séptico, queimado ou cirúrgico; as dietas utilizadas deveriam conter um ou mais dos imunonutrientes, em qualquer dose, administradas por via enteral comparadas à dieta padrão pela mesma via em pelo menos um dos grupos de comparação. As bases de dados consultadas foram Pubmed e Cinhal, utilizando os termos: Immunonutrition, arginine, glutamine, n-3, nucleotides e criticall illness. De 206 artigos encontrados inicialmente, apenas 35 preencheram os critérios de elegibilidade estabelecidos. Destes 35 ensaios clínicos, 18 foram conduzidos em pacientes cirúrgicos, 6 em pacientes traumatizados, 5 em pacientes queimados, 5 em pacientes críticos em geral e 1 em pacientes sépticos. Para a população geral, não houve redução significativa do risco de morrer indicada pelo RR de 0,84 (IC de 0,68 a 1,05) e os queimados foram mais protegidos de morrer com RR de 0,25 (IC de 0,09 a 0,66); as complicações infecciosas foram reduzidas com RR de 0,56 (IC de 0,42 a 0,73); a incidência de sepse foi reduzida com RR de 0,45 (IC de 0,29 a 0,69), especialmente nos pacientes traumatizados com RR de 0,42 (IC de 0,26 a 0,68); a incidência de abscesso abdominal também foi reduzida com RR de 0,39 (IC de 0,21 a 0,72) e também de bacteremia com RR de 0,46 (IC de 0,31 a 0,66); o tempo de internação hospitalar diminuiu -3,9 dias (IC de -5,0 a -2,8). Para a população de pacientes cirúrgicos: o óbito não apresentou redução significativa do RR de 0,93 (IC de 0,44 a 1,95), as complicações infecciosas foram reduzidas com RR de 0,51 (IC de 0,41 a 0,63), o tempo de internação hospitalar foi reduzido - 3,41 dias (IC de -4,25 a -2,58) e o tempo de internação em UTI -1,72 dias (IC de -2,12 a -1,31). A utilização de dietas com nutrientes imunomoduladores não alterou a mortalidade em doentes críticos ou cirúrgicos. Indivíduos com mais de 60 anos são menos protegidos de morrer pela utilização de dietas com imunomoduladores. As complicações infecciosas são reduzidas em pacientes críticos com a utilização de imunonutrição, em especial a população de pacientes cirúrgicos. Dietas com mais de 10g/l de arginina protegem mais os pacientes críticos da incidência de complicações infecciosas. Pacientes traumatizados são protegidos da incidência de sepse pela utilização da imunonutrição. O tempo de internação hospitalar e o tempo de internação em UTI foram reduzidos em críticos e cirúrgicos com imunonutrição. A execução de ensaios clínicos explanatórios nos diferentes tipos de doentes críticos com um nutriente imunomodulador isolado, seguida de ensaios pragmáticos de acordo com os resultados dos anteriores, é um fato a ser considerado em futuras pesquisas.

Uso seguro de opioides no paciente queimado: proposta de barreiras pela enfermagem

A tese desenvolvida neste estudo é que a depressão respiratória em pacientes queimados que utilizam opiódes como terapeutica farmacológica da dor, pode ser prevenida por meio de ações de enfermagem que identifiquem os fatores predisponentes para a depressão respiratória, que considerem na rotina de aprazamento da terapeutica farmacológica da dor, as características farmacológicas dos medicamentos, para evitar interações medicamentosas e que monitorem adequadamente o paciente queimado para identificar precocemente sinais de depressão respiratória. Para tanto, este estudo teve como objetivo desenvolver barreiras de segurança com foco em ações de enfermagem, para prevenção de depressão respiratória em pacientes queimados em uso de opióides. Trata-se de um estudo restrospectivo, em que foram analisados 272 prontuários de pacientes queimados internados em um Centro de Tratamento de Queimados (CTQ), de um hospital público federal de grande porte, no município do Rio de Janeiro. nos anos de 2011 a 2013. Dentre os 272 prontuários 42 atenderam os critérios de seleção da pesquisa, e destes, em 28,58% (n=12) foi identificada a ocorrência de depressão respiratória. Predominaram pacientes adultos jovens do sexo masculino. O óbito predominou no grupo com DR, assim como, queimaduras de 2 e 3 graus, e superfície corporal queimada com mediana de 50%. Os fatores predominantes para depressão respiratória foram insuficiencia renal, hipoalbuminemia e hipertensão arterial. Na terapia medicamentosa dos pacientes queimados, os analgésicos opióides são os mais utilizados, predominando o tramadol (45,49%) e a metadona (18,45%). Diazepam é o benzodiazepínico de escolha, entre os antidepressivos a imipramina é o mais utilizado, apesar de classificada como anticonvulsivantes a gabapentina, nos queimados é utilizada em dose analgésica. Tanto no grupo de pacientes com ou sem DR, os horários de adiministração de medicamentos que predominaram foram 22h e 06h. Foi evidenciado PIM em 66,6% dos pacientes estudados. A associação entre a ocorrência de PIM e a DR demonstrou-se positiva; os pacientes com que apresentaram PIM têm 2,5 vezes mais risco de apresentar DR. Os pares de medicamentos prevalentes e que apresentaram PIM no grupo com DR foram, metadona com diazepam (n=5), tramadol com fentanil (4), metadona com impramina e metadona com tramadol (n=3). No grupo sem DR foram metadona e tramadol (n=8), tramadol com fentanil (4), e metadona com diazepam (3). As vias oral e intravenosa predominaram nos pacientes com e sem DR, e não houve associação positiva entre a administração por essas vias e a oorrência de DR, constatando-se que a via de administração não é tão relevante para a DR. Nos pacientes com DR, 83,3% apresentaram PIM, principalmente nos horários 22h e 06h, horários próximos aos de ocorrência de DR. Espera-se que este estudo contribua para a segurança medicamentosa no uso de opióides, e na prevenção do eventos adverso grave como a depressão respiratória em pacientes queimados.

El Niño-Southern Oscillation (ENSO) phenomena and forest fires in the southwestern United States

Fire statistics (area burned) and fire-scar chronologies from tree rings show reduced fire activity during El Niño-Southern Oscillation (ENSO) in forests of Arizona and New Mexico. This relationship probably stems from increased fuel moisture after a wet winter and spring, but also could involve climatic controls on lightning activity at the onset of the monsoon season.

The internal structure of igniting turbulent sprays as revealed by complex chemistry DNS

A parametric study of spark ignition in a uniform monodisperse turbulent spray is performed with complex chemistry three-dimensional Direct Numerical Simulations in order to improve the understanding of the structure of the ignition kernel. The heat produced by the kernel increases with the amount of fuel evaporated inside the spark volume. Moreover, the heat sink by evaporation is initially higher than the heat release and can have a negative effect on ignition. With the sprays investigated, heat release occurs over a large range of mixture fractions, being high within the nominal flammability limits and finite but low below the lean flammability limit. The burning of very lean regions is attributed to the diffusion of heat and species from regions of high heat release, and from the spark, to lean regions. Two modes of spray ignition are reported. With a relatively dilute spray, nominally flammable material exists only near the droplets. Reaction zones are created locally near the droplets and have a non-premixed character. They spread from droplet to droplet through a very lean interdroplet spacing. With a dense spray, the hot spark region is rich due to substantial evaporation but the cold region remains lean. In between, a large surface of flammable material is generated by evaporation. Ignition occurs there and a large reaction zone propagates from the rich burned region to the cold lean region. This flame is wrinkled due to the stratified mixture fraction field and evaporative cooling. In the dilute spray, the reaction front curvature pdf contains high values associated with single droplet combustion, while in the dense spray, the curvature is lower and closer to the curvature associated with gaseous fuel ignition kernels. © 2011 The Combustion Institute.

Sleeping sites of Rhinopithecus bieti at Mt. Fuhe, Yunnan

Data on sleeping site selection were collected for a group of black-and-white snub-nosed monkeys (Rhinopithecus bieti; around 80) at Mt. Fuhe, Yunnan, China (99degrees20'E, 26degrees25'N, about 3,000 m asl) from November 2000 to January 2002. At the site mainly three vegetation types were present in an elevation-ascending order: deciduous broad leaf forest, mixed coniferous and broad leaf forest, and dark coniferous forest. In addition, bamboo forest presented in areas burned in 1958. Sleeping sites (n = 10) were located in the coniferous forest, where trees were the tallest, bottommost branches were the highest, the diameter of crowns was the second largest, and the gradient of the ground was the steepest. Monkeys usually kept quiet during entering and staying at a sleeping site. The site choice and the quietness may be tactics to avoid potential predators. In the coniferous forest, however, monkeys did not sleep in the valley bottom where trees were the largest, but frequently slept in the middle of the slope towards the east/southeast, in the shadow of ridges in three other directions, to avoid strong wind and to access sunshine; in winter-spring, they ranged in a more southern and lower area than in summer-autumn. These may be behavioral strategies to minimize energy stress in the cold habitat. Monkeys often slept in the same sleeping site on consecutive nights, which reflected a reduced pressure of predation probably due to either the effectiveness of anti-predation through sleeping site selection, or the population decline of predators with increasing human activities in the habitat. The group's behavioral responses to interactive and sometimes conflicting traits of the habitat are site-specific and conform to expectations for a temperate zone primate.

Full cost accounting for the life cycle of coal.

Each stage in the life cycle of coal-extraction, transport, processing, and combustion-generates a waste stream and carries multiple hazards for health and the environment. These costs are external to the coal industry and are thus often considered "externalities." We estimate that the life cycle effects of coal and the waste stream generated are costing the U.S. public a third to over one-half of a trillion dollars annually. Many of these so-called externalities are, moreover, cumulative. Accounting for the damages conservatively doubles to triples the price of electricity from coal per kWh generated, making wind, solar, and other forms of nonfossil fuel power generation, along with investments in efficiency and electricity conservation methods, economically competitive. We focus on Appalachia, though coal is mined in other regions of the United States and is burned throughout the world.

Effect of operating conditions and fuel type on crevice hc emissions: Model results and comparison with experiments

A one-dimensional model for crevice HC post-flame oxidation is used to calculate and understand the effect of operating parameters and fuel type (propane and isooctane) on the extent of crevice hydrocarbon and the product distribution in the post flame environment. The calculations show that the main parameters controlling oxidation are: bulk burned gas temperatures, wall temperatures, turbulent diffusivity, and fuel oxidation rates. Calculated extents of oxidation agree well with experimental values, and the sensitivities to operating conditions (wall temperatures, equivalence ratio, fuel type) are reasonably well captured. Whereas the bulk gas temperatures largely determine the extent of oxidation, the hydrocarbon product distribution is not very much affected by the burned gas temperatures, but mostly by diffusion rates. Uncertainties in both turbulent diffusion rates as well as in mechanisms are an important factor limiting the predictive capabilities of the model. However, it seems well suited to sensitivity calculations about a baseline. Copyright © 1999 Society of Automotive Engineers, Inc.

Numerical simulation of post-flame oxidation of hydrocarbons in spark ignition engines

About 50-90 percent of the hydrocarbons that escape combustion during flame passage in spark-ignition engine operation are oxidized in the cylinder before leaving the system. The process involves the transport of unreacted fuel from cold walls towards the hotter burned gas regions and subsequent reaction. In order to understand controlling factors in the process, a transient one-dimensional reactive-diffusive model has been formulated for simulating the oxidation processes taking place in the reactive layer between hot burned gases and cold unreacted air/fuel mixture, with initial and boundary conditions provided by the emergence of hydrocarbons from the piston top land crevice. Energy and species conservation equations are solved for the entire process, using a detailed chemical kinetic mechanism for propane. Simulation results show that the post-flame oxidation process takes place within a reactive layer where intermediate hydrocarbon products are formed at temperatures above 1100-1200 K, followed by a carbon monoxide conversion region closer to the hot burned gases. Model results show that most of hydrocarbons leaving the crevice are completely oxidized inside the cylinder. The largest contribution of remaining hydrocarbons are those leaving the crevice at temperatures below 1400 K. The largest fraction of non-fuel (intermediate) hydrocarbons results from hydrocarbons leaving the crevice when core temperatures are around 1400 K Copyright © 1997 Society of Automotive Engineers, Inc.

Use of axially graded burnable boron for hot-spot temperature reduction in a pressurized water reactor core

Shortly after the loading of a pressurized water reactor (PWR) core, the axial power distribution in fresh fuel has already attained the characteristic, almost flat shape, typical of burned fuel. At beginning of cycle (BOC), however, the axial distribution is centrally peaked. In assemblies hosting uniform burnable boron rods, this BOC peaking is even more pronounced. A reduction in the axial peaking is today often achieved by shortening the burnable boron rods by some 30 cm at each edge. It is shown that a two-zone grading of the boron rod leads, in a representative PWR cycle, to a reduction of the hot-spot temperature of approximately 70 °C, compared with the nongraded case. However, with a proper three-zone grading of the boron rod, an additional 20 °C may be cut off the hot-spot temperature. Further, with a slightly skewed application of this three-zone grading, an additional 50 °C may be cut off. The representative PWR cycle studied was cycle 11 of the Indian Point 2 station, with a simplification in the number of fuel types and in the burnup distribution. The analysis was based on a complete three-dimensional burnup calculation. The code system was ELCOS, with BOXER as an assembly code for the generation of burnup-dependent cross sections and SILWER as a three-dimensional core code with thermal-hydraulic feedback.

Statistics of reaction progress variable and mixture fraction gradients from DNS of turbulent partially premixed flames

Statistically planar turbulent partially premixed flames for different initial intensities of decaying turbulence have been simulated for global equivalence ratios = 0.7 and 1.0 using three-dimensional, simplified chemistry-based direct numerical simulations (DNS). The simulation parameters are chosen such that the flames represent the thin reaction zones regime combustion. A random bimodal distribution of equivalence ratio is introduced in the unburned gas ahead of the flame to account for the mixture inhomogeneity. The results suggest that the probability density functions (PDFs) of the mixture fraction gradient magnitude |Δξ| (i.e., P(|Δξ|)) can be reasonably approximated using a log-normal distribution. However, this presumed PDF distribution captures only the qualitative nature of the PDF of the reaction progress variable gradient magnitude |Δc| (i.e., P(|Δc|)). It has been found that a bivariate log-normal distribution does not sufficiently capture the quantitative behavior of the joint PDF of |Δξ| and |Δc| (i.e., P(|Δξ|, |Δc|)), and the agreement with the DNS data has been found to be poor in certain regions of the flame brush, particularly toward the burned gas side of the flame brush. Moreover, the variables |Δξ| and |Δc| show appreciable correlation toward the burned gas side of the flame brush. These findings are corroborated further using a DNS data of a lifted jet flame to study the flame geometry dependence of these statistics. © 2013 Copyright Taylor and Francis Group, LLC.

Local strain rate and curvature dependences of scalar dissipation rate transport in turbulent premixed flames: A direct numerical simulation analysis

The statistical behaviours of the instantaneous scalar dissipation rate Nc of reaction progress variable c in turbulent premixed flames have been analysed based on three-dimensional direct numerical simulation data of freely propagating statistically planar flame and V-flame configurations with different turbulent Reynolds number Ret. The statistical behaviours of N c and different terms of its transport equation for planar and V-flames are found to be qualitatively similar. The mean contribution of the density-variation term T1 is positive, whereas the molecular dissipation term (-D2) acts as a leading order sink. The mean contribution of the strain rate term T2 is predominantly negative for the cases considered here. The mean reaction rate contribution T3 is positive (negative) towards the unburned (burned) gas side of the flame, whereas the mean contribution of the diffusivity gradient term (D) assumes negative (positive) values towards the unburned (burned) gas side. The local statistical behaviours of Nc, T1, T2, T 3, (-D2), and f(D) have been analysed in terms of their marginal probability density functions (pdfs) and their joint pdfs with local tangential strain rate aT and curvature km. Detailed physical explanations have been provided for the observed behaviour. © 2014 Y. Gao et al.

Influences of catalysis and dispersion of organically modified montmorillonite on flame retardancy of polypropylene nanocomposites

The degradation and flame retardancy of polypropylene/organically modified montmorillonite (PP/OMMT) nanocomposite were studied by means of gas chromatography-mass spectrometry and cone calorimeter. The catalysis of hydrogen proton containing montmorillonite (H-MMT) derived from thermal decomposition of (alkyl) ammonium in the OMMT on degradation of PP strongly influence carbonization behavior of PP and then flame retardancy. Bronsted acid sites on the H-MMT could catalyze degradation reaction of PP via cationic mechanism, which leads to the formation of char during combustion of PP via hydride transfer reaction. A continuous carbonaceous MMT-rich char on the surface of the burned residues, which work as a protective barrier to heat and mass transfer, results from the homogeneous dispersion of OMMT in the PP matrix and appropriate char produced.

Global fire emissions and the contribution of deforestation, savanna, forest, agricultural, and peat fires (1997-2009)

New burned area datasets and top-down constraints from atmospheric concentration measurements of pyrogenic gases have decreased the large uncertainty in fire emissions estimates. However, significant gaps remain in our understanding of the contribution of deforestation, savanna, forest, agricultural waste, and peat fires to total global fire emissions. Here we used a revised version of the Carnegie-Ames-Stanford-Approach (CASA) biogeochemical model and improved satellite-derived estimates of area burned, fire activity, and plant productivity to calculate fire emissions for the 1997-2009 period on a 0.5° spatial resolution with a monthly time step. For November 2000 onwards, estimates were based on burned area, active fire detections, and plant productivity from the MODerate resolution Imaging Spectroradiometer (MODIS) sensor. For the partitioning we focused on the MODIS era. We used maps of burned area derived from the Tropical Rainfall Measuring Mission (TRMM) Visible and Infrared Scanner (VIRS) and Along-Track Scanning Radiometer (ATSR) active fire data prior to MODIS (1997-2000) and estimates of plant productivity derived from Advanced Very High Resolution Radiometer (AVHRR) observations during the same period. Average global fire carbon emissions according to this version 3 of the Global Fire Emissions Database (GFED3) were 2.0 PgC year-1 with significant interannual variability during 1997-2001 (2.8 Pg Cyear-1 in 1998 and 1.6 PgC year-1 in 2001). Globally, emissions during 2002-2007 were rela-tively constant (around 2.1 Pg C year-1) before declining in 2008 (1.7 Pg Cyear-1) and 2009 (1.5 PgC year-1) partly due to lower deforestation fire emissions in South America and tropical Asia. On a regional basis, emissions were highly variable during 2002-2007 (e.g., boreal Asia, South America, and Indonesia), but these regional differences canceled out at a global level. During the MODIS era (2001-2009), most carbon emissions were from fires in grasslands and savannas (44%) with smaller contributions from tropical deforestation and degradation fires (20%), woodland fires (mostly confined to the tropics, 16%), forest fires (mostly in the extratropics, 15%), agricultural waste burning (3%), and tropical peat fires (3%). The contribution from agricultural waste fires was likely a lower bound because our approach for measuring burned area could not detect all of these relatively small fires. Total carbon emissions were on average 13% lower than in our previous (GFED2) work. For reduced trace gases such as CO and CH4, deforestation, degradation, and peat fires were more important contributors because of higher emissions of reduced trace gases per unit carbon combusted compared to savanna fires. Carbon emissions from tropical deforestation, degradation, and peatland fires were on average 0.5 PgC year-1. The carbon emissions from these fires may not be balanced by regrowth following fire. Our results provide the first global assessment of the contribution of different sources to total global fire emissions for the past decade, and supply the community with an improved 13-year fire emissions time series. © 2010 Author(s).

Phase II Archaeological Excavations at 99 Main Street, 18AP21 (Sign of the Whale), Annapolis, Maryland

Historical Annapolis Foundation (HAF) conducted terrestrial archaeological investigations at site 18AP21 in the city of Annapolis, Maryland. Excavations were carried out at this National Register site ostensibly as a Phase II project to evaluate the site and assess the need for further work. The site is at 99 Main Street in the center of downtown Annapolis, near the Annapolis waterfront. The project was carried out as part of the advanced work for the Annapolis History Center project, to be built in the adjoining buildings of 99 Main and 196 Green Streets. The buildings are the property of the Historic Annapolis Foundation and located in Maryland Research Unit 7. The excavations were undertaken by HAF, and funded by HAFF. The work was conducted for HAF and MHT, who holds an archaeological easement on the property. This preliminary phase of work included stratigraphic excavation of two testpit units. These two units revealed that the site of the existing 99 Main Street building was the location of three previous constructions. The current building at 99 Main Street, built in 1791, was preceded by an earlier brick dwelling, evidenced by a stout pier of bricks, which was attached to a wooden-sided structure that stood on a foundation of brick and stone. Ceramics indicate that these buildings date to the early-middle of the 18th century. A third structure of post-in-ground construction, evidenced by recovery of burned posts and wood fragments, likely existed prior to these, but evidence was scant. These excavations reveal that the site of 18AP21 holds potential for understanding Annapolis's early cultural developments, especially in the area of initial settlement and the origins of waterfront commerce. The assemblage of artifacts recovered includes a broad sample of common 18th century pottery such as creamware and Chinese export porcelain, and also includes some early colonial types such as tin-glazed earthenware and various red-bodied slipwares. The excavations do not provide conclusive evidence of the construction sequence. Consultation with MHT representatives indicates that further work at the site will likely be needed before modifications to the floor of the building can progress.

Simulation of the Unsteady Gas Flow through a Three-way Automotive Catalyst

This paper describes a model of a 1.8-litre four-cylinder four-stroke gasoline engine fitted with a close-coupled three-way catalyst (TWC). Designed to meet EURO 3 emissions standards, the engine includes some advanced emission control features in addition to the TWC, namely: variable valve timing (VVT), swirl control plates, and exhaust gas recirculation (EGR). Gas flow is treated as one-dimensional (1D) and unsteady in the engine ducting and in the catalyst. Reflection and transmission of pressure waves at the boundaries of the catalyst monolith are modelled. In-cylinder combustion is represented by a two-zone burn model with dissociation and reaction kinetics. A single Wiebe analysis of measured in-cylinder pressure data is used to determine the mass fraction burned as a function of crank angle (CA) at each engine speed. Measured data from steady-state dynamometer tests are presented for operation at wide open throttle (WOT) over a range of engine speeds. These results include CA-resolved traces of pressure at various locations throughout the engine together with cycle-averaged traces of gas composition entering the catalyst as indicated by a fast-response emissions analyser. Simulated engine performance and pressure wave action throughout the engine are well validated by the measured data.