Mechanical ventilation in Spain, 1998-2016: Changes in the disconnection of mechanical ventilation.

PURPOSE: To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. DESIGN: Post-hoc analysis of four cohort studies. AMBIT: 138 Spanish ICUs. PATIENTS: 2141 patients scheduled extubated. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. RESULTS: There was a significant increase (p < 0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p = 0.435). CONCLUSIONS: There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed.

Survival outcomes and prognostic factors of endometrial stromal sarcoma and undifferentiated uterine sarcoma.

PURPOSE: To review the diagnostic and therapeutic procedures of patients diagnosed with Endometrial Stromal Sarcoma (ESS) and Undifferentiated Uterine Sarcoma (USS) at our institution and investigate their clinical outcomes and factors affecting prognosis. METHODS: We retrospectively collected demographic data, preoperative diagnostic methods and therapeutic management of patients treated for ESS and UUS between January 1995 and December 2019 at Vall d'Hebron Barcelona Hospital Campus, Spain. Overall survival and disease-free survival were calculated. Cox proportional-hazards regression models were calculated. RESULTS: Sixty-three patients were included in the study, of which 51(81%) had a diagnosis of ESS and 12(19%) of UUS. Twenty patients (31.7%) were diagnosed after a previous non-oncologic surgery, and 12 of them (60%) suffered from tumor disruption. Cytoreductive procedures were needed in 29 patients (46%), and optimal cytoreduction was achieved in 80.9% of the patients. The median follow-up was 7.6 years (IQR = 0.99-14.31). Five-year overall survival was 57.6% (44.2-68.8) and was significantly better for low-grade ESS (LG-ESS) patients (p < 0.01). Five-year disease-free survival was 57.1% (42.8-69.1) and was also significantly higher in LG-ESS cohort (p = 0.03). After multivariate analysis histological type, age, FIGO stage, optimal surgery and mitotic index were found significantly correlated with survival. For high-grade EES (HG-ESS) and USS patients adjuvant radiotherapy also correlated with improved survival. CONCLUSION: Overall survival and disease-free survival are significantly better in patients with LG-ESS cohort. HG-ESS and UUS show similar survival outcomes. Age, FIGO stage, optimal surgery and histological type were significantly correlated with survival in the global cohort, whilst adjuvant radiotherapy correlated with improved survival in HG-ESS and UUS patients.

Mechanical ventilation in Spain, 1998-2016: Epidemiology and outcomes. / Ventilación mecánica en España, 1998-2016: epidemiología y desenlaces.

PURPOSE: To evaluate changes in the epidemiology of mechanical ventilation in Spain from 1998 to 2016. DESIGN: A post hoc analysis of four cohort studies was carried out. SETTING: A total of 138 Spanish ICUs. PATIENTS: A sample of 4293 patients requiring invasive mechanical ventilation for more than 12h or noninvasive ventilation for more than 1h. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographic variables, reason for mechanical ventilation, variables related to ventilatory support (ventilation mode, tidal volume, PEEP, airway pressures), complications during mechanical ventilation, duration of mechanical ventilation, ICU stay and ICU mortality. RESULTS: There was an increase in severity (SAPSII: 43 points in 1998 vs. 47 points in 2016), changes in the reason for mechanical ventilation (decrease in chronic obstructive pulmonary disease and acute respiratory failure secondary to trauma, and increase in neurological disease and post-cardiac arrest). There was an increase in noninvasive mechanical ventilation as the first mode of ventilatory support (p<0.001). Volume control ventilation was the most commonly used mode, with increased support pressure and pressure-regulated volume-controlled ventilation. A decrease in tidal volume was observed (9ml/kg actual b.w. in 1998 and 6.6ml/kg in 2016; p<0.001) as well as an increase in PEEP (3cmH2O in 1998 and 6cmH2O in 2016; p<0.001). In-ICU mortality decreased (34% in 1998 and 27% in 2016; p<0.001), without geographical variability (median OR 1.43; p=0.258). CONCLUSIONS: A significant decrease in mortality was observed in patients ventilated in Spanish ICUs. These changes in mortality could be related to modifications in ventilation strategy to minimize ventilator-induced lung injury.

Mechanical ventilation in Spain, 1998-2016: changes in the disconnection of mechanical ventilation. / Ventilación mecánica en España, 1998-2016: cambios en la desconexión de la ventilación mecánica.

PURPOSE: To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. DESIGN: Post-hoc analysis of four cohort studies. AMBIT: 138 Spanish ICUs. PATIENTS: 2141 patients scheduled extubated. INTERVENTIONS: None. VARIABLES OF INTEREST: Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. RESULTS: There was a significant increase (p<0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p=0.435). CONCLUSIONS: There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed.

Analysis of results of soft tissue sarcoma margins revision surgery. / Análisis de resultados en cirugía de revisión de márgenes de sarcomas de partes blandas.

INTRODUCTION: Patients from other centres where they have had an unplanned surgical resection of a soft tissue sarcoma are often referred to hospitals specialised in sarcomas. MATERIAL AND METHODS: A study was conducted on 35 patients who required this type of surgery were referred to our center between November 2001 and July 2013. RESULTS: Surgery had been performed on 29% of the patients without any complementary tests being done. In 75% of cases, the sarcoma diagnosis was discovered in the post-surgical histological study. Synovial sarcoma was the most common, affecting 38% of the patients. A surgical revision of the margins was performed on all of them, and adjuvant treatment was performed on 86% of them. The histopathology study found that 69% of the patients had residual disease. At the end of follow-up, 12% had a local recurrence, another 12% distant metastases, and 3% had died. CONCLUSION: Given the results, it is concluded that any tumour of the soft tissues in which malignancy is suspected has to be resected in a reference centre. If an unplanned esection was performed in another centre, it should be referred immediately in order to perform an imaging study, revision surgery, and if required, adjuvant treatment.

Cardiac tamponade by aortic dissection in a hospital without cardiothoracic surgery.

A 48-year-old male patient had arrest due to rupture of a dissecting aneurysm of the thoracic aorta into the pericardial cavity with tamponade; he received treatment in a general hospital lacking the facilities to practice heart surgery. The patient was treated by means of intermittent pericardial drainage while being transferred to another hospital at 100-km distance for surgical treatment.

Inhibition of [3H]forskolin binding by Gpp[NH]p may reflect adenylyl cyclase coupling to Gi.

The effect of the GTP-analogue guanylyl 5'-imidodiphosphate (Gpp[NH]p) on [3H]forskolin binding was studied in rat brain using autoradiography. In the striatum, 100 microM Gpp[NH]p produced a 40% increase in binding, whereas a decrease of about 30% was observed with low Gpp[NH]p concentrations (0.1-1 microM). In the molecular layer of the cerebellum all concentrations of Gpp[NH]p decreased [3H]forskolin binding. The decrease in binding disappeared in both striatum and the molecular layer of cerebellum in sections pretreated with 100 microM N-ethylmaleimide (NEM) for 10 min. NEM pretreatment did not significantly affect the stimulation of [3H]forskolin binding by micromolar concentrations of Gpp[NH]p in the striatum, but reversed the decrease observed in the molecular layer of the cerebellum, to an increase. Based on these data we suggest that the effects of the GTP-analogue Gpp[NH]p on [3H]forskolin binding may involve both Gs and Gi, where a stimulation produces an increase and decrease in binding respectively. The regional effects of Gpp[NH]p may reflect differences in the responsiveness of adenylyl cyclase to Gs and Gi-mediated effects.

Inhibition of [3H]forskolin binding by Gpp[NH]p may reflect adenylate cyclase coupling to Gi.

The effect of the GTP analogue guanylyl-5'-imidodiphosphate (Gpp[NH]p) on [3H]forskolin binding was studied in rat brain using autoradiography. In the striatum the presence of 100 microM Gpp[NH]p produced a 40% increase in binding, whereas a decrease of about 30% was observed with low Gpp[NH]p concentrations (0.1 microM). In the molecular layer of the cerebellum all concentrations of Gpp[NH]p decreased [3H]forskolin binding. The decrease in binding disappeared in both striatum and the molecular layer of cerebellum in sections pretreated with 100 microM N-ethylmaleimide (NEM) for 10 min. NEM pretreatment did not significantly affect the stimulation of [3H]forskolin binding by micromolar concentrations of Gpp[NH]p in the striatum, but reversed the decrease observed in the molecular layer of the cerebellum, to an increase. Based on these data we suggest that the effects of Gpp[NH]p on [3H]forskolin binding may involve both Gs and Gi, where stimulation produces an increase and decrease in binding, respectively. The regional effects of Gpp[NH]p may reflect differences in the responsiveness of adenylate cyclase to Gs- and Gi-mediated effects.

Quantitative autoradiography of [3H]forskolin binding sites in post-mortem brain staged for Alzheimer's disease neurofibrillary changes and amyloid deposits.

Adenylyl cyclase (AC) signal transduction has been shown to be affected in Alzheimer's disease (AD). Deficits have been described in different components of the system, from the receptor to the effector level. [3H]forskolin is a diterpene that binds with high affinity to AC. In the present report, we used autoradiography to study [3H]forskolin binding to sections of entorhinal cortex and hippocampus from 23 cases staged for AD pathology according to Braak and Braak [Acta Neuropathol. 82 (1991) 239-259]. This protocol defines six stages according to neurofibrillary changes, which start in the entorhinal region (stages I-II), spread to the hippocampus (stages III-IV) and finally to the isocortical areas (stages V-VI). The amyloid classification includes three stages in which the basal isocortex is first affected (stage A), followed by other isocortical association areas (stage B) and finally the primary isocortical areas (stage C). We also studied the effects of the GTP-analogue Gpp[NH]p on binding, in order to detect changes in G-protein-AC coupling. We used two different concentrations of Gpp[NH]p, that were previously reported to inhibit and stimulate [3H]forskolin binding via Gi and Gs, respectively. Results showed that [3H]forskolin binding declined significantly with staging for neurofibrillary changes only in the entorhinal region (P < 0.05, ANOVA). In addition, the decrease in [3H]forskolin binding observed in the presence of 1 microM Gpp[NH]p diminished significantly with staging in the entorhinal region (P < 0.05, ANOVA). No significant changes were seen with amyloid staging, with the exception of the CA1 subfield of the hippocampus, where [3H]forskolin binding in the absence of Gpp[NH]p was significantly decreased at stage B compared with all other stages (P < 0.05, ANOVA). In conclusion, our results showed a very limited decrease in [3H]forskolin binding with the progression of AD pathology, suggesting that the AC levels may be largely preserved in the disease. The specific change in the effect of a low concentration of Gpp[NH]p on the binding could indicate the loss of Ca2+/calmodulin-sensitive AC isoforms in AD.

Carcinoid tumor of the uterine corpus. A case report.

BACKGROUND: Carcinoid tumors are neoplasms of neuroendocrine origin that rarely affect the genital tract. CASE: A 75-year-old woman underwent hysterectomy and bilateral adnexectomy due to vaginal bleeding and uterine pathology (leiomyoma, cervical low grade squamous intraepithelial lesions and endometrial hyperplasia on ultrasound). Pathologic examination of the specimen disclosed a uterine corpus carcinoid tumor. The patient had been taking tamoxifen for adjuvant treatment of breast cancer diagnosed and treated seven years before. CONCLUSION: A review of the literature revealed one case of carcinoid tumor of the uterine wall. There does not appear to be any relationship between tamoxifen and the carcinoid tumors reported.

Malignant vulvo-vaginal melanoma: a report of 7 cases.

To evaluate the clinical outcome of patients suffering from primary vulvo-vaginal malignant melanoma retrospective review of clinical and pathological data of six patients with vulvar malignant melanoma and one patient with vaginal melanoma was done. Patients were staged using the 1988 FIGO histological classification for vulvar cancer, and the 1992 American Joint Committee on Cancer (AJCC) classification for malignant melanoma of the skin. Clinical features, type of surgery, adjuvant therapy, recurrences, distant metastasis, and survival were recorded. Of 174 primary cancers of the vulva, six were malignant melanomas (3.4%), the second most common cause of vulvar cancer. Within the same period, only one primary vaginal melanoma was detected among 57 primary vaginal cancers (1.7%). The median age of all patients was 71 (range 61-84). We performed different surgical procedures, including a radical local excision of the lesion in the vaginal melanoma, a radical hemivulvectomy in one case, a radical vulvectomy in an other case, and a radical vulvectomy with lymph node dissection en bloc in three cases. According to the 1988 FIGO classification for vulvar carcinomas, three patients were diagnosed as stage I and four as stage III melanomas; and using the 1992 AJCC classification for malignant melanoma of the skin, all patients were staged as stage III. Two out of five patients, with a follow-up longer than two years, continued to live and were disease free at the last check-up (40%): the rest of them (60%) died of disease 2.9 months after the diagnosis of the distant metastasis. Vulvo-vaginal malignant melanomas are neoplasias with a very poor prognosis and a short period of time between the detection of distant metastasis and death. Although treatment is not clear in vaginal melanoma, the most accepted treatment in vulvar melanomas is the radical local excision of the lesion with a homolateral inguinofemoral lymphadenectomy.

Uterine sarcoma: a clinicopathological study of 93 cases.

OBJECTIVE: To evaluate the clinical outcome of patients suffering from primary uterine sarcoma diagnosed and treated in our Hospital. SETTING: Department of Gynecologic Surgery/Gynecologic Oncology, Hospital Universitario Materno-Infantil Vall d'Hebron de Barcelona, Barcelona, Spain. SUBJECTS AND METHODS: A retrospective review from 1967 to 1995 of clinical and pathological characteristics of 93 patients with primary uterine sarcoma was done. Patients were staged using the 1988 FIGO histological classification for uterine cancer. Clinical features, type of surgery, adjuvant therapy, recurrences, distant metastasis, and survival were recorded. RESULTS: Our study included three main histologic types: 44 patients with leiomyosarcoma, 26 patients with endometrial stromal sarcoma, and 18 patients with mixed Müllerian sarcomas. The mean age for all patients was 54.8 years, and the most common symptom was vaginal bleeding. Other clinicopathological features were examined. Although surgery was the most frequent treatment, adjuvant therapies have been analyzed and discussed. The overall three-year survival rate was 67.9% and the overall five-year survival rate was 64.5%. We found statistical differences (p < 0.001) between the stage I survival rate and other stage survival rates. CONCLUSIONS: Uterine sarcoma is an uncommon neoplasia diagnosed in the 6th decade of life. Leiomyosarcoma is the most frequent histologic type (47.3%). Stage I uterine sarcoma has a better prognosis than other stages.

[Hemorrhagic shock and fulminant hepatic failure associated with valproate]. / Shock hemorrágico e insuficiencia hepática fulminante asociada a valproato.

Fulminant hepatic failure is an uncommon adverse effect of valproate treatment. Despite an increased use of valproate, since the drug was introduced in 1978, a decline in the number of reported cases has been observed. Here a case of hemorrhagic shock and fulminant hepatic failure in a patient treated with valproate is presented. We emphasize the diagnostic difficulties from the point of view of recognition of the clinical manifestations as well as the biochemical monitoring.

[Severe ischemic colitis in a patient with acute myocardial infarction]. / Colitis isquémica severa en paciente con infarto agudo de miocardio.

We discuss a case of a 68 years old man with an acute myocardial infarction and a cardiopulmonary arrest that 3 days after his admission developed a continuous abdominal pain and findings of peritoneal inflammation. The mesenteric angiographical study was normal. A laparotomy was practised and disclosed a local peritonitis and a colonic infarction without mesenteric vascular occlusion. This picture is very unusual in patients with acute myocardial infarction or cardiopulmonary arrest.

[Cholestasis and listeriosis in the third trimester of pregnancy]. / Colestasis y listeriosis en el tercer trimestre de la gestación.

Listeriosis is an infection produced by Listeria monocytogenes. It is infrequent and affects people at extreme ages, pregnant women, immunocompromised people and, occasionally, healthy people. Its incidence has increased in recent years and shows a certain tendency to seasonality, increasing in summer. It can appear sporadically or as outbreaks. In pregnant women the infection is most frequently produced in the third trimester and the symptoms are usually light. Nonetheless, the infection of the fetus is severe, and can produce miscarriages, fetal deaths, corioamnionitis and premature births with the newborn infected, manifested in the form of granulomatosis infantiseptica with abscesses and scattered granulomas or at a later stage , as meningitis or sepsis. Intrahepatic cholestasis is a reversible form of cholestasis, its cause is unknown, it is specific to pregnancy and is more frequent in multiparous women, in the third trimester and rarely before the 26th week. It disappears following childbirth and is the second cause of jaundice in pregnancy, after hepatitis. The diagnosis of cholestasis is basically clinical. It appears as palmoplantar pruritus but can also produce nausea, vomiting and abdominal discomfort localized in the right hypochondrium. Given that listeriosis and cholestasis can have a shared symptomology, the possibility of listeriosis must be borne in mind in order for early implementation of the mechanisms of diagnostic confirmation (cultivation of sterile fluids or tissues: blood, neonatal CSF, amniotic liquid or placenta) and specific treatment. We present a case of cholestasis and listeriosis in the third trimester with a good maternofetal result.