Estudio Anatómico y Prevalencia del Canalis sinuosus Evaluado Mediante Cone Beam CT en Pacientes Chilenos / Anatomical Study and Prevalence of Canalis sinuosus Evaluated by Cone Beam CT in Chilean Patients

Canalis sinuosus, canal intraóseo localizado en región maxilar anterior, contiene elementos vasculonerviosos alveolares anterosuperiores. Diversas intervenciones en región maxilar anterior como colocación de implantes, exodoncias, instalación de microtornillos ortodóncicos, procedimientos quirúrgicos, entre otros, pueden comprometer al Canalis sinuosus y/o sus canales accesorios dañando los elementos contenidos en su interior causando complicaciones como hemorragias, parestesia, disestesia, etc. Dado el gran desconocimiento de su existencia, el Canalis sinuosus frecuentemente es confundido con lesiones patológicas y/o endodónticas. Clásicamente la literatura lo describe como una variación anatómica variación anatómica, sin embargo, presenta elevadas prevalencias (51,7 %-100 %), siendo cuestionada esta aseveración. Determinar prevalencia y característica s anatómicas del Canalis sinuosus mediante Cone Beam CT en pacientes chilenos del centro radiológico IMAPROX® entre 2017- 2021. Análisis retrospectivo de 220 CBCT maxilares anonimizados, considerando variables sexo, presencia del Canalis sinuosus, Canalis sinuosus uni/bilateral, diámetro mayor del Canalis sinuosus, presencia/número de accesorios. Análisis estadístico uni y bivariado. 100 % de prevalencia del Canalis sinuosus en ambos sexos, presencia bilateral 100 %. Diámetro mayor promedio del Canalis sinuosus: 2,58 mm. El 76,8 % presentó accesorios, siendo más prevalente la presencia de 2 CA (34,1 %). Una estructura anatómica normal habitual debe presentar sobre 50 % de prevalencia para ser considerada como tal, pero no hay consensos en criterios empleados para definir variación anatómica o estructura anatómica normal habitual. Literatura describe al Canalis sinuosus como variación anatómica, pero estudios actuales muestran elevadas prevalencias: Rusia 67 %, Brasil 88 %, Turquía, Colombia y Chile 100 %. Este estudio encontró 100 % de prevalencia, sugiriendo que Canalis sinuosus es una estructura anatómica normal habitual. Sin embargo, Canalis sinuosus es poco conocido asociándose a numerosas complicaciones por procedimientos odontológicos y/o quirúrgicos en RMA pudiendo generar hemorragias, parestesia/disestesia, dolor agudo, etc. Elevadas prevalencias reportadas sugieren que Canalis sinuosus es una estructura anatómica normal habitual y no una variación anatómica, pero se requieren más estudios y consensos para aseverarlo. Es de relevancia clínica conocer la existencia y localización del Canalis sinuosus para evitar complicaciones.

Canalis sinuosus, an intraosseous canal located in the anterior maxillary region, contains anterosuperior alveolar vascular-nervous elements. Various interventions in anterior maxillary region such as implant placement, extractions, installation of orthodontic microscrews, surgical procedures, among others, can compromise the Canalis sinuosus and/or its accessory canals, damaging the elements contained inside, causing complications such as bleeding, paresthesia, dysesthesia, etc. Given the great ignorance of its existence, Canalis sinuosus is frequently confused with pathological and/or endodontic lesions. Classically, the literature describes it as an anatomical variation, however, it presents high prevalence (51.7 %-100 %), this assertion being questioned. Objective: to determine the prevalence and anatomical characteristics of Canalis sinuosus using Cone Beam CT in Chilean patients from the IMAPROX® radiological center between 2017-2021. Retrospective analysis of 220 anonymous maxillary CBCT, considering variables sex, presence of Canalis sinuosus, uni/bilateral Canalis sinuosus, largest diameter of Canalis sinuosus, presence/number of accessory canals. Univariate and bivariate statistical analysis. The 100 % prevalence of Canalis sinuosus in both sexes, 100 % bilateral presence. Canalis sinuosus average major diameter: 2.58 mm, 76.8 % presented accessory canals, with the presence of 2 accessory canals being more prevalent (34.1 %). A habitual normal anatomical structure must have a prevalence of over 50 % to be considered as such, but there is no consensus on the criteria used to define anatomical variation or normal anatomical structure. Literature describes Canalis sinuosus as anatomical variation, but current studies show high prevalence: Russia 67 %, Brazil 88 %, Turkey, Colombia and Chile 100 %. This study found 100 % prevalence, suggesting that Canalis sinuosus is an normal anatomical structure. However, Canalis sinuosus is little known as it is associated with numerous complications from dental and/or surgical procedures in anterior maxillary region, which can cause bleeding, paresthesia/ dysesthesia, acute pain, etc. High reported prevalences suggest that Canalis sinuosus is an normal anatomical structure and not an anatomical variation, but more studies and consensus are required to confirm this. It is clinically relevant to know the existence and location of Canalis sinuosus to avoid complications.

Five-year outcome of peripherally inserted central catheters in adults: a separated infectious and thrombotic complications analysis.

OBJECTIVE: To assess infectious and thrombotic complications of peripherally inserted central catheters (PICCs) in adults. DESIGN: A 5-year prospective cohort study. SETTING: Tertiary-care teaching hospital in Seville, Spain. PATIENTS: Adult patients undergoing PICC insertion. METHODS: Catheter-associated bloodstream infection (CABSI) including catheter-related bloodstream infection (CRBSI), primary bacteremia (PB), and upper extremity deep vein thrombosis (UEDVT) were recorded. Independent predictors of complications were assessed by multivariate analysis. RESULTS: In total, 1,142 PICCs were inserted, with 153,191 catheter days (median, 79). Complications included 66 cases of CABSI (5.78%; 0.43‰ catheter days), 38 cases of CRBSI (3.33%; 0.25‰ catheter days), 28 cases of PB (2.45%; 0.18‰ catheter days), and 23 cases of UEDVT (2.01%; 0.15‰ catheter days). The median times to infection were 24, 41, and 60 days for CRBSI, PB, and UEDVT, respectively. Parenteral nutrition (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.77-6.52) and admission to the hematology ward (OR, 4.90; 95% CI, 2.25-10.71) were independently associated with CRBSI and PB, respectively. Admission to the hematology ward (OR, 12.46; 95% CI, 2.49-62.50) or to the oncology ward (OR, 7.89; 95% CI, 1.77-35.16) was independently associated with UEDVT. The crude mortality rate was 24.8%. Only 2 patients died of complications. CONCLUSIONS: PICCs showed a low rate of thrombotic and infectious complications. Compared to PB, CRBSI showed significantly different risk factors, a higher incidence density per catheter days, and a shorter median time to infection. Separate analyses of CRBSI and PB are more specific and clinically useful when analyzing infectious complications.

A randomized, placebo-controlled trial of preemptive antifungal therapy for the prevention of invasive candidiasis following gastrointestinal surgery for intra-abdominal infections.

BACKGROUND: Patients undergoing emergency gastrointestinal surgery for intra-abdominal infection are at risk of invasive candidiasis (IC) and candidates for preemptive antifungal therapy. METHODS: This exploratory, randomized, double-blind, placebo-controlled trial assessed a preemptive antifungal approach with micafungin (100 mg/d) in intensive care unit patients requiring surgery for intra-abdominal infection. Coprimary efficacy variables were the incidence of IC and the time from baseline to first IC in the full analysis set; an independent data review board confirmed IC. An exploratory biomarker analysis was performed using logistic regression. RESULTS: The full analysis set comprised 124 placebo- and 117 micafungin-treated patients. The incidence of IC was 8.9% for placebo and 11.1% for micafungin (difference, 2.24%; [95% confidence interval, -5.52 to 10.20]). There was no difference between the arms in median time to IC. The estimated odds ratio showed that patients with a positive (1,3)-ß-d-glucan (ßDG) result were 3.66 (95% confidence interval, 1.01-13.29) times more likely to have confirmed IC than those with a negative result. CONCLUSIONS: This study was unable to provide evidence that preemptive administration of an echinocandin was effective in preventing IC in high-risk surgical intensive care unit patients with intra-abdominal infections. This may have been because the drug was administered too late to prevent IC coupled with an overall low number of IC events. It does provide some support for using ßDG to identify patients at high risk of IC. CLINICAL TRIALS REGISTRATION: NCT01122368.

ß-D-Glucan and Candida albicans germ tube antibody in ICU patients with invasive candidiasis.

PURPOSE: To assess the performance of (1→3)-ß-D-glucan (BDG) and Candida albicans germ tube antibody (CAGTA) for the diagnosis of invasive candidiasis (IC) in a prospective cohort of 107 unselected, non-neutropenic ICU patients. METHODS: BDG (cutoff positivity ≥80 pg/mL) and CAGTA (cutoff positivity ≥1/160) assays were performed twice a week. Confounding factors included amoxicillin-clavulanate and piperacillin-tazobactam treatments, recent surgery, Gram-positive bloodstream infection, renal replacement therapy, and enteral nutrition. Patients were classified as neither colonized nor infected (n = 29), Candida spp. colonization (n = 63) (low grade, n = 32; high grade, n = 31), and invasive candidiasis (IC) (n = 15). RESULTS: BDG levels were higher in patients with IC and high-grade colonization than in the remaining groups (p = 0.012), and two consecutive measurements ≥80 pg/mL discriminated IC from the remaining groups (sensitivity 80%, specificity 75.7%). For the discrimination between IC and Candida spp. colonization, the AUC for the maximum value of BDG was 0.667 (95% CI 0.544-0.790) and for the maximum value of CAGTA 0.545 (95% CI 0.395-0.694). Significant changes of BDG and CAGTA kinetics in IC patients treated with antifungals were not observed. In patients neither colonized nor infected or with low-grade Candida spp. colonization, none of the confounding factors was associated with a significant increase in BDG positivity. CONCLUSIONS: Two consecutive BDG levels ≥80 pg/mL allowed discrimination among IC and high-grade colonization. Systemic antifungal therapy could not be monitored with biomarker kinetics, and BDG levels were not subject to interference by confounding factors in either colonized or infected patients or with low-grade colonization.

What's new in the clinical and diagnostic management of invasive candidiasis in critically ill patients.

Invasive candidiasis (IC) is a severe complication in the ICU setting. A high proportion of ICU patients become colonized with Candida species, but only 5-30 % develop IC. Progressive colonization and major abdominal surgery are well-known risk factors for Candida infection. IC is difficult to predict and early diagnosis remains a major challenge. In addition, microbiological documentation often occurs late in the course of infection. Delays in initiating appropriate treatment have been associated with increased mortality. In an attempt to decrease Candida-related mortality, an increasing number of critically ill patients without documented IC receive empirical systemic antifungal therapy, leading to concern for antifungal overuse. Scores/predictive rules permit the stratification and selection of IC high-risk patients who may benefit from early antifungal therapy. However, they have a far better negative predictive value than positive predictive value. New IC biomarkers [mannan, anti-mannan, (1,3)-ß-D-glucan, and polymerase chain reaction] are being increasingly used to enable earlier diagnosis and, ideally, to provide prognostic information and/or therapeutic monitoring. Although reasonably sensitive and specific, these techniques remain largely investigational, and their clinical usefulness has yet to be established.

[Guidelines for the treatment of Invasive Candidiasis and other yeasts. Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC). 2010 Update]. / Recomendaciones sobre el tratamiento de la candidiasis invasiva y otras infecciones por levaduras de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC). Actualización 2011.

These guidelines are an update of the recommendations of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) that were issued in 2004 (Enferm Infecc Microbiol Clin. 2004, 22:32-9) on the treatment of Invasive Candidiasis and infections produced by other yeasts. This 2010 update includes a comprehensive review of the new drugs that have appeared in recent years, as well as the levels of evidence for recommending them. These guidelines have been developed following the rules of the SEIMC by a working group composed of specialists in infectious diseases, clinical microbiology, critical care medicine, paediatrics and oncology-haematology. It provides a series of general recommendations regarding the management of invasive candidiasis and other yeast infections, as well as specific guidelines for prophylaxis and treatment, which have been divided into four sections: oncology-haematology, solid organ transplantation recipients, critical patients, and paediatric patients.

Usefulness of the "Candida score" for discriminating between Candida colonization and invasive candidiasis in non-neutropenic critically ill patients: a prospective multicenter study.

OBJECTIVE: To assess the usefulness of the "Candida score" (CS) for discriminating between Candida species colonization and invasive candidiasis (IC) in non-neutropenic critically ill patients. A rate of IC <5% in patients with CS <3 was the primary end point. DESIGN: Prospective, cohort, observational study. SETTING: Thirty-six medical-surgical intensive care units of Spain, Argentina, and France. PATIENTS: A total of 1,107 non-neutropenic adult intensive care unit patients admitted for at least 7 days between April 2006 and June 2007. MEASUREMENTS AND MAIN RESULTS: Clinical data, surveillance cultures for fungal growth, and serum levels of (1-3)-beta-d-glucan and anti-Candida antibodies (in a subset of patients) were recorded. The CS was calculated as follows (variables coded as absent = 0, present = 1): total parenteral nutrition x1, plus surgery x1, plus multifocal Candida colonization x1, plus severe sepsis x2. A CS >or=3 accurately selected patients at high risk for IC. The colonization index was registered if >or=0.5. The rate of IC was 2.3% (95% confidence interval [CI] 1.06-3.54) among patients with CS <3, with a linear association between increasing values of CS and IC rate (p 7 days, with a CS <3 and not receiving antifungal treatment, the rate of IC was <5%. Therefore, IC is highly improbable if a Candida-colonized non-neutropenic critically ill patient has a CS <3.

Risk factors for candidaemia in critically ill patients: a prospective surveillance study.

Candidaemia is frequently a life-threatening complication in patients admitted to the intensive care unit (ICU). To assess the risk factors for candidaemia in critically ill patients with prolonged ICU stay, a total of 1765 adult patients admitted for at least 7 days to 73 medical-surgical ICUs of 70 tertiary care hospitals in Spain participated in a prospective cohort study. Candidaemia was defined as recovery of Candida spp. from blood culture. Sixty-eight episodes of candidaemia occurred in 63 patients, representing 35.7 episodes per 1000 ICU patients admitted, with an incidence rate of 1.5 episodes per 1000 days of ICU stay. Causative fungi were C. albicans in 57.1% of cases and non-albicans Candida spp. in 42.9%. In the multivariate analysis, independent factors significantly associated with candidaemia were Candida colonisation (OR = 4.12, 95% CI: 1.82-9.33), total parenteral nutrition (OR = 3.89, 95% CI: 1.73-8.78), elective surgery (OR = 2.75, 95% CI: 1.17-6.45) and haemofiltration procedures (OR = 1.96, 95% CI: 1.06-3.62). In the ICU setting in Spain and in patients who have stayed in units for >7 days, more than half of cases of candidaemia were caused by C. albicans. Risk factors for candidaemia identified included Candida colonisation, elective surgery, total parenteral nutrition and haemodialysis.

A bedside scoring system ("Candida score") for early antifungal treatment in nonneutropenic critically ill patients with Candida colonization.

OBJECTIVE: To obtain a score for deciding early antifungal treatment when candidal infection is suspected in nonneutropenic critically ill patients. DESIGN: Analysis of data collected from the database of the EPCAN project, an ongoing prospective, cohort, observational, multicenter surveillance study of fungal infection and colonization in intensive care unit (ICU) patients. SETTING: Seventy-three medical-surgical ICUs of 70 teaching hospitals in Spain. PATIENTS: A total of 1,699 ICU patients aged 18 yrs and older admitted for at least 7 days between May 1998 and January 1999 were studied. INTERVENTIONS: Surveillance cultures of urine, tracheal, and gastric samples were obtained weekly. Patients were grouped as follows: neither colonized nor infected (n=719), unifocal or multifocal Candida colonization (n=883), and proven candidal infection (n=97). The odds ratio (OR) for each risk factor associated with colonization vs. proven candidal infection was estimated. A logistic regression model was performed to adjust for possible confounders. The "Candida score" was obtained according to the logit method. The discriminatory power was evaluated by the area under the receiver operating characteristics curve. MEASUREMENTS AND MAIN RESULTS: In the logit model, surgery (OR=2.71, 95% confidence interval [CI], 1.45-5.06); multifocal colonization (OR=3.04, 95% CI, 1.45-6.39); total parenteral nutrition (OR=2.48, 95% CI, 1.16-5.31); and severe sepsis (OR=7.68, 95% CI, 4.14-14.22) were predictors of proven candidal infection. The "Candida score" for a cut-off value of 2.5 (sensitivity 81%, specificity 74%) was as follows: parenteral nutrition, +0.908; surgery, +0.997; multifocal colonization, +1.112; and severe sepsis, +2.038. Central venous catheters were not a significant risk factor for proven candidal infection (p=.292). CONCLUSIONS: In a large cohort of nonneutropenic critically ill patients in whom Candida colonization was prospectively assessed, a "Candida score">2.5 accurately selected patients who would benefit from early antifungal treatment.

[Indications for antifungal treatment in intensive care unit patients]. / Indicaciones del tratamiento antifúngico en pacientes ingresados en servicios de medicina intensiva*

INTRODUCTION: This study investigates the indications for antifungal treatment in patients admitted to intensive care units (ICUs) in Spain and determines the frequency at which each individual drug is prescribed. METHODS: Observational, multicenter study including all patients admitted to 64 ICUs on 23 March, 22 June, and 16 November, 1999. The use of antifungal agents and the criteria for indicating antifungal therapy were assessed. Patients were classified as colonized or infected by fungi. RESULTS: In 180 (11.5%) of the 1562 patients included in the study, 219 courses of treatment with antifungal agents were prescribed (antifungal therapy rate of 14 per 100 patients). Fluconazole was the antifungal agent most frequently used, both in infected and colonized patients. The most common reasons for prescribing antifungal therapy were as follows: candiduria (21.9%), severe sepsis with no response to antibiotic therapy (19.6%), and evidence of fungi in two or more non-invasive sites (16.9%). Candidemia was the reason for antifungal treatment in 17 (7.9%) cases. Proven fungal infections accounted for 21.1% of indications. Variables significantly associated with the use of antifungal agents included underlying disease, severity of illness according to the APACHE II score, chronic liver disease, solid tumor, immunosuppression, and organ transplantation. Significant extrinsic risk factors for antifungal therapy included treatment with corticoids, chemotherapy, mechanical ventilation, urgent and/or elective surgery, and previous use of antibiotics. CONCLUSIONS: A total of 11.5% of patients included in the study were given one or more treatment courses with antifungal agents. Antifungal treatment was prescribed in proved fungal infections in only 21.1% of cases. Fluconazole was the antifungal agent most frequently used.

[Fungal colonization and/or infection in intensive care units. Multicenter study of 1,562 patients]. / Colonización y/o infección por hongos en unidades de cuidados intensivos. Estudio multicéntrico de 1.562 pacientes.

BACKGROUND AND OBJECTIVE: Our objective was to assess the frequency of fungal colonization and/or infection in critically ill patients admitted to intensive care units (ICUs) and to describe the characteristics and risk factors of those patients in whom fungi had been isolated. PATIENTS AND METHOD: Observational, multicenter study of patients admitted to 64 ICUs on March 23, June 22, and November 16, 1999. In these patients, the presence of fungi was investigated in some biological sample from the day of ICU admission to the day of assessment of fungal infection. Patients were classified as colonized or infected by fungi. RESULTS: A total of 1,562 patients were included: 686 in the first period, 567 in the second, and 309 in the third, with a mean of 24.4 patients per ICU (range, 9-62). Fungi were isolated in 456 biological samples from 248 patients (15.9 patients per each series of 100 controlled patients): lung in 183 (40.1%) cases, urine in 90 (19.7%) cases, and oropharynx in 46 (10.1%) cases. Fungi were isolated in blood cultures in 17 (3.7%) patients. Candida albicans was the most frequently isolated fungal species in all sites (68.9%). Isolation of fungi allowed a diagnosis of fungal infection in 121 patients (fungal infection rate, 7.7 episodes per 100 patients admitted to the ICU). Individual risk factors for fungal infection were as follows: previous use of antimicrobials (OR=5.01; 95% CI, 1.77-14.2); mechanical ventilation (OR=3.45; 95% CI, 1.61-7.40); urgent surgical procedures (OR = 2.44; 95% CI, 1.59-3.74); solid neoplasm (OR=2.32; 95% CI, 1.29-4.19); use of corticosteroids (OR = 1.88; 95% CI, 1.18-2.99); and APACHE II score (OR=1.05; 95% CI, 1.02-1.07). CONCLUSIONS: Fungi were isolated in 15.9% patients admitted to ICUs and they were the causative agents of infection in 7.7% of cases. Candida albicans predominated in all sites. Risk factors for fungal infection included previous use of antibiotics, mechanical ventilation, urgent surgery, solid tumor, use of corticosteroids, and intermediate severity of illness according to the APACHE II score.