Background The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. MethodsIn this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63•8%) were men, and 14 524 (46•5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71•9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27•5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88•7%] of 195 patients with open fractures; 426 [44•7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47•7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50•5%]), while Second Delays ...

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aRossi FS, Mascaretti RS, Haddad LB, Freddi NA, Mauad T, Rebello CM. Utilization of the lower inflection point of the pressure-volume curve results in protective conventional ventilation comparable to high frequency oscillatory ventilation in an animal model of acute respiratory distress syndrome. Clinics. 2008;63:237-44. INTRODUCTION:Studies comparing high frequency oscillatory and conventional ventilation in acute respiratory distress syndrome have used low values of positive end-expiratory pressure and identified a need for better recruitment and pulmonary stability with high frequency. OBJECTIVE: To compare conventional and high frequency ventilation using the lower inflection point of the pressure-volume curve as the determinant of positive end-expiratory pressure to obtain similar levels of recruitment and alveolar stability. METHODS: After lung lavage of adult rabbits and lower inflection point determination, two groups were randomized: conventional (positive end-expiratory pressure = lower inflection point; tidal volume=6 ml/kg) and high frequency ventilation (mean airway pressures= lower inflection point +4 cmH 2 O). Blood gas and hemodynamic data were recorded over 4 h. After sacrifice, protein analysis from lung lavage and histologic evaluation were performed. RESULTS: The oxygenation parameters, protein and histological data were similar, except for the fact that significantly more normal alveoli were observed upon protective ventilation. High frequency ventilation led to lower PaCO 2 levels. DISCUSSION: Determination of the lower inflection point of the pressure-volume curve is important for setting the minimum end expiratory pressure needed to keep the airways opened. This is useful when comparing different strategies to treat severe respiratory insufficiency, optimizing conventional ventilation, improving oxygenation and reducing lung injury. CONCLUSIONS: Utilization of the lower inflection point of the pressure-volume curve in the ventilation strategies considered in this study resulted in comparable efficacy with regards to oxygenation and hemodynamics, a high PaCO 2 level and a lower pH. In addition, a greater number of normal alveoli were found after protective conventional ventilation in an animal model of acute respiratory distress syndrome.

Introduction Electrical impedance tomography (EIT) is a noninvasive, radiation-free, bedside tool to monitor ventilation distribution in real time. Objective To evaluate, in pediatric COVID-19 patients, the ventilation distribution using EIT and compare it to thoracic computed tomography (TCT) or chest radiograph results obtained in these patients. Methods This was a prospective, observational clinical study including pediatric patients admitted to the intensive care unit of a private hospital. The patients monitored with EIT tested positive for COVID-19 and were submitted to the previously mentioned radiation exams. EIT monitoring lasted 15 min and no sedation was used. Results Six patients were included in this study. The main differences observed in the EIT were in the right-left distribution and were compatible with the morphological changes found in the TCT or radiograph images due to COVID-19 infection. Conclusion We conclude that EIT is ready to investigate the ventilatory profile present at different lung diseases, including COVID-19, and might postpone or mitigate the need of repeated ionizing radiation exams in the pediatric population, although larger pediatric cohorts comparing to standard radiological imaging are needed.

Background: There is an important increase in the use of whole body computed tomography (WBCT) around the world although its benefits are still controversial.We hypothesized that the use of a WBCT protocol in the major trauma patients based on mechanism of injury alone would reduce the number of injuries that would have been missed if CT was only done based on clinical findings. Study design:A prospective observational study with the inclusion of 144 patients with major blunt trauma during 5 months at our academic center. Data were collected from all patients including: epidemiology, clinical status on scene and at the emergency department, time of the scan (including patient handling), clinical findings during initial assessment and WBCT scan findings, dividing exams in with or without findings (normal). Looking for findings that would go unnoticed if CT was done based on clinical findings. Glasgow coma scale (GCS) 15 and GCS <15 were compared and data are presented as absolute values of mean ± SD. Analysis of data was done with Chi-square test (p < 0.05). Results:One hundred forty-four patients with major trauma that were included in the protocol. Normal CT scan was found in 44 cases and 100 scans had at least one positive finding associated with the trauma and 35 CTs (25%) had at least one injury that would be missed without the WBCT protocol. Glasgow coma scale of 15 patients and those with 14 or less were compared regarding the number of normal vs positive scan (p = 0.45) and for scans with unnoticed injuries (p = 0.1) and there was no difference between the two groups.Conclusion: A significant number of injuries would have been missed if a WBCT scan protocol based on mechanism of injury was not used in our center. There was no difference in the number of probably missed injuries in patients with a GCS = 15 or those with GCS ≤ 14.

Objectives: To evaluate the effects of four flow rates on the functional residual capacity (FRC) and pulmonary ventilation distribution while using a high-flow nasal cannula (HFNC).Working Hypothesis: Our hypothesis is that flow rates below 1.5 L•kg −1 •min −1 lead to FRC loss and respiratory distress.

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