Kinetics of humoral deficiency in CART19-treated children and young adults with acute lymphoblastic leukaemia.

CD19-CAR T-cell therapy (CART19) causes B-cell aplasia (BCA) and dysgammaglobulinemia but there is a lack of information about the degree of its secondary immunodeficiency. We conducted a prospective study in children and young adults with acute lymphoblastic leukaemia treated with CART19, analysing the kinetics of BCA and dysgammaglobulinemia during therapy, as well as the B-cell reconstitution in those with CART19 loss. Thirty-four patients were included (14 female) with a median age at CART19 infusion of 8.7 years (2.9-24.9). Median follow-up after infusion was 7.1 months (0.5-42). BCA was observed 7 days after infusion (3-8), with persistence at 24 months in 60% of patients. All patients developed a progressive decrease in IgM and IgA: 71% had undetectable IgM levels at 71 days (41-99) and 13% undetectable IgA levels at 185 days (11-308). Three of 12 patients had protective levels of IgA in saliva. In two of three patients who lost CART19, persistent B-cell dysfunction was observed. No severe infections occurred. In conclusion, BCA occurs soon after CART19 infusion, with a progressive decrease in IgM and IgA, and with less impairment of IgA, suggesting the possibility of an immune reservoir. A persistent B-cell dysfunction might persist after CART19 loss in this population.

[Informed consent for anaesthesia: Presential or non-presential information?] / Consentimiento informado de anestesia: ¿información presencial o no presencial?

INTRODUCTION: The anaesthesia informed consent (AIC) is a process of communication between a clinician and a patient that results in the patient agreeing to undergo a specific anaesthetic procedure after understanding all the information needed to make a free, voluntary and conscious decision. This information is traditionally given during a face-to-face pre-operative visit. OBJECTIVE: To evaluate patient perceptions when they receive the information about AIC, face-to-face or by phone. PATIENTS AND METHODS: A single centre, randomised, double-blind, parallel-group pilot clinical trial was conducted on patients > 18 years of age undergoing major ambulatory surgery procedures with a surgical complexity that did not require a face-to-face pre-operative visit. Patients were randomly assigned to be informed by telephone (experimental group) or in a face- to-face visit (control group). Fifteen days after the surgery a questionnaire was used to gather patient perceptions in understanding the anaesthetic procedure and risks, autonomy (to ask for explanations), as well as and satisfaction. RESULTS: Of the 160 patients that gave their consent, 142 were interviewed: 70 from the experimental group and 72 from the control group. Both groups were comparable in age, gender, anaesthetic risk, and surgical complexity. The percentage of patients that understood the information provided on the anaesthetic technique was 71% and 81%, respectively (P=.429); on its risks: 67% and 69% (P=.951); autonomy: 56% and 74% (P=.036) and satisfaction rate: 46% and 46% (P=.835). CONCLUSION: There is no difference between the groups in the level of understanding of the information that the patient perceives and the level of satisfaction. Nevertheless, almost half of them did not remember to have been given the possibility to clear-up doubts.

[Epidural vs. intradural anesthesia in ambulatory surgery]. / Anestesia epidural frente a anestesia intradural en cirugía ambulatoria.

Spinal anesthesia is the technique of choice for many outpatient procedures. With appropriate screening and preparation, it can provide excellent surgical conditions and highly satisfactory anesthesia for the patient, while remaining cost-effective. Intradural anesthesia has advantages over epidural anesthesia: technical simplicity, rapid onset, efficacy and depth of blockade. Its use has been controversial, however, for many years due to the potential risk of headache after puncture of the dura mater. Epidural anesthesia causes fewer hemodynamic changes and provides greater dose flexibility and local anesthetic concentration, with less risk of headache after accidental puncture of the dura mater. The drawbacks are that it takes longer to perform and onset of blockade comes later. Both techniques are valid alternatives to general anesthesia in outpatient surgery. The choice of one over the other will depend on patient characteristics, availability of a presurgical area, and the anesthesiologist's skill.

[Efficacy of the ilioinguinal and iliohypogastric block in the treatment of the postoperative pain of inguinal herniorrhaphy]. / Eficacia del bloqueo ilioinguinal e iliohipogástrico en el tratamiento del dolor postoperatorio de la herniorrafia inguinal.

INTRODUCTION: The ileoinguinal-ileohypogastric block (IHB) improves pain control in inguinal hernioplasty. OBJECTIVE: To determine the efficacy of the IHB on the treatment of postoperative pain in inguinal herniorrhaphy, and to compare the effect of its use before and after incision for diminishing pain and postponing the first dose of analgesia. PATIENTS AND METHODS: Sixty-eight patients scheduled for inguinal herniorrhaphy with mesh were enrolled and distributed randomly in 4 groups as follows: 1) IHB before incision using 0.25 ml/kg bupivacaine 0.5% with no vasoconstrictor; 2) IHB after incision with the same dose of bupivacaine; 3) IHB before incision with 0.25 ml/kg of serum; and 4) IHB after incision with 0.25 ml/kg of serum. Pain was evaluated on visual analog scales employing facial expressions and verbal description, a patient questionnaire and time elapsing between surgery and the first dose of analgesia. The evaluations were performed in the postoperative recovery unit and on the ward 8 and 24 hours after surgery. RESULTS: The total overall score for postoperative pain was lower in the bupivacaine group than in the placebo group (9.2 +/- 4.4 and 1.5 +/- 3.9, respectively; p = 0.026). The first dose of analgesia was given to those who received placebo between the second and third hour after surgery, whereas it was given between the fourth and fifth hour to the bupivacaine group. No significant differences were found between infiltration before and after incision. CONCLUSIONS: IHB decreases pain, delaying the need for a first dose of analgesic and improving patient comfort. Its use is therefore recommended for relief of postoperative pain.

[Evaluation of anesthetic techniques in ambulatory surgery]. / Evaluación de las técnicas anestésicas en cirugía ambulatoria.

Many of the surgical procedures performed in the hospital can be done on an out-patient basis, provided an appropriate anesthetic technique is applied to allow the patient to return home comfortably and safely. Choice of anesthetic technique must always be made in keeping with patient characteristics and type of surgery. Treatment of anxiety in a preoperative interview or by giving tranquilizers will be beneficial to all patients, as will reduction of gastric secretion by administration of H2 receptor blockers. Dehydrobenzoperidol at a dose of 0.5 to 1.125 mg in adults will antagonize the emetic effects of opioids, without prolonging recovery time. Propofol, alfentanyl, atracurium or vecuronium require the shortest recovery time. For epidural anesthesia, we use lidocaine and mepivacaine. Truncal blocks, endovenous regional anesthesia, and brachial plexus, retrobulbar and peribulbar blocks are all appropriate techniques for out-patient surgery.

Oxygen transport of hemoglobin in high-altitude animals (Camelidae).

To clarify the mechanisms by which high-altitude Camelidae can adapt to hypoxia, the study of some blood characteristics were carried out in apacas and llamas. The results show that there is a peculiar dissociation curve of hemoglobin in alpacas which permits great affinity of hemoglobin for oxygen at lung level and the release of oxygen at the tissue level with a facility similar to that in man. Fetal hemoglobin was found high in adult alpacas (55 percent). Electrophoretic studies of hemoglobin showed that this pigment has two components, both of which have a very low mobility. Lactic dehydrogenase was found six times higher than in humans. RBC glucose-6-phosphate dehydrogenase was two times higher than in man living at the same altitude. Myoglobin was found to be higher than in man living at altitude. Alpacas have erythrocytes in which the amount of 2,3-DPG is approximately the same as in man. RBC are more resistent to hypotonic solutions than humans. The amount of lactic dehydrogenase, myoglobin, and glucose-6-phosphate dehydrogenase dimishes when alpacas are bought down to sea level.