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Journal of Forensic Sciences Sep 2021The illegal construction of explosive devices for recreational purposes has become increasingly widespread in recent years. This phenomenon is spurred on by numerous...
The illegal construction of explosive devices for recreational purposes has become increasingly widespread in recent years. This phenomenon is spurred on by numerous websites that explain how to build a self-made device. The correlation between the use of firearms and suicide is known in the literature, but the use of explosive devices and self-harm is little studied. Unfortunately, the risk associated with the manufacture of homemade explosives is poorly known. For this purpose, we describe a rare suicide carried out by a man suffering from depressive disorder with psychotic and delusional features. The forensic investigations at the scene showed that the man had designed a homemade device, and disseminated numerous suicide notes in his home, transcribed in the previous weeks in which he revealed his suicidal motivation. Crime scene investigation showed on the body and on the road in front of the explosion point: multiple fragments of glass (zone 1), a lighter with blood stains (zone 2), and shreds of clothing scattered along the road (zone 3). Autopsy revealed that the cause of death was extensive blunt injury to head and trunk due to barotrauma due to the explosion of a homemade device. The case is compared with data from a systematic review of the forensic literature on suicides involving explosives. The study proposes the analysis of planimetric areas in these crime scene investigations and active surveillance in these subjects.
Topics: Aged; Blast Injuries; Explosive Agents; Forensic Medicine; Humans; Male; Suicide, Completed
PubMed: 34042187
DOI: 10.1111/1556-4029.14757 -
The Cochrane Database of Systematic... Mar 2021In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has been associated with ventilator-induced lung injury. High levels of positive end-expiratory pressure (PEEP) could reduce this condition and improve patient survival. This is an updated version of the review first published in 2013.
OBJECTIVES
To assess the benefits and harms of high versus low levels of PEEP in adults with ALI and ARDS.
SEARCH METHODS
For our previous review, we searched databases from inception until 2013. For this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and the Web of Science from inception until May 2020. We also searched for ongoing trials (www.trialscentral.org; www.clinicaltrial.gov; www.controlled-trials.com), and we screened the reference lists of included studies.
SELECTION CRITERIA
We included randomised controlled trials that compared high versus low levels of PEEP in ALI and ARDS participants who were intubated and mechanically ventilated in intensive care for at least 24 hours.
DATA COLLECTION AND ANALYSIS
Two review authors assessed risk of bias and extracted data independently. We contacted investigators to identify additional published and unpublished studies. We used standard methodological procedures expected by Cochrane.
MAIN RESULTS
We included four new studies (1343 participants) in this review update. In total, we included 10 studies (3851 participants). We found evidence of risk of bias in six studies, and the remaining studies fulfilled all criteria for low risk of bias. In eight studies (3703 participants), a comparison was made between high and low levels of PEEP, with the same tidal volume in both groups. In the remaining two studies (148 participants), the tidal volume was different between high- and low-level groups. In the main analysis, we assessed mortality occurring before hospital discharge only in studies that compared high versus low PEEP, with the same tidal volume in both groups. Evidence suggests that high PEEP may result in little to no difference in mortality compared to low PEEP (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.04; I² = 15%; 7 studies, 3640 participants; moderate-certainty evidence). In addition, high PEEP may result in little to no difference in barotrauma (RR 1.00, 95% CI 0.64 to 1.57; I² = 63%; 9 studies, 3791 participants; low-certainty evidence). High PEEP may improve oxygenation in patients up to the first and third days of mechanical ventilation (first day: mean difference (MD) 51.03, 95% CI 35.86 to 66.20; I² = 85%; 6 studies, 2594 participants; low-certainty evidence; third day: MD 50.32, 95% CI 34.92 to 65.72; I² = 83%; 6 studies, 2309 participants; low-certainty evidence) and probably improves oxygenation up to the seventh day (MD 28.52, 95% CI 20.82 to 36.21; I² = 0%; 5 studies, 1611 participants; moderate-certainty evidence). Evidence suggests that high PEEP results in little to no difference in the number of ventilator-free days (MD 0.45, 95% CI -2.02 to 2.92; I² = 81%; 3 studies, 1654 participants; low-certainty evidence). Available data were insufficient to pool the evidence for length of stay in the intensive care unit.
AUTHORS' CONCLUSIONS
Moderate-certainty evidence shows that high levels compared to low levels of PEEP do not reduce mortality before hospital discharge. Low-certainty evidence suggests that high levels of PEEP result in little to no difference in the risk of barotrauma. Low-certainty evidence also suggests that high levels of PEEP improve oxygenation up to the first and third days of mechanical ventilation, and moderate-certainty evidence indicates that high levels of PEEP improve oxygenation up to the seventh day of mechanical ventilation. As in our previous review, we found clinical heterogeneity - mainly within participant characteristics and methods of titrating PEEP - that does not allow us to draw definitive conclusions regarding the use of high levels of PEEP in patients with ALI and ARDS. Further studies should aim to determine the appropriate method of using high levels of PEEP and the advantages and disadvantages associated with high levels of PEEP in different ARDS and ALI patient populations.
Topics: Acute Disease; Adult; Bias; Humans; Intensive Care Units; Length of Stay; Oxygen Consumption; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Tidal Volume; Ventilator-Induced Lung Injury
PubMed: 33784416
DOI: 10.1002/14651858.CD009098.pub3 -
Frontiers in Pharmacology 2019The therapeutic role of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial.
BACKGROUND
The therapeutic role of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial.
METHODS
We systematically reviewed randomized controlled trials investigating the use of NMBA in ARDS patients from inception to July 2019. Relative risk (RR) was calculated for the incidence of barotrauma and mortality using the random-effect or fixed-effect model according to heterogeneity analysis.
RESULTS
Data were combined from five randomized controlled trials that included 1,461 patients (724 in the NMBA group and 737 in the control group). Pooled analysis showed that NMBA infusion did not reduce 28-day mortality (RR = 0.72, 95% confidence interval (CI) 0.44 to 1.17, =0.180, I-squared = 62.8%), but was associated with lower intensive care unit (ICU) mortality (RR = 0.60, 95% CI 0.41 to 0.88, = 0.009, I-squared = 9.2%). In addition, the incidence of barotrauma was significantly lower in patients treated with NMBA (RR = 0.53, 95% CI 0.33 to 0.84, = 0.007, I-squared = 0). However, infusion of NMBA might increase the risk of ICU-acquired weakness (RR = 1.34, 95% CI 0.97 to 1.84, = 0.066, I-squared = 0).
CONCLUSION
Infusion of NMBA could reduce ICU mortality and the incidence of barotrauma. The risk of ICU-acquired weakness was higher in moderate-to-severe ARDS patients treated with NMBA. The real effects of NMBA need to be further evaluated and confirmed by a study with a stricter design.
PubMed: 32063852
DOI: 10.3389/fphar.2019.01637