Unraveling the Predictors for Delirium and ICU Stay Duration in Patients with Heart Failure and Reduced Ejection Fraction (HFrEF) Undergoing Coronary Artery Bypass Grafting-A Multicentric Analysis.

Objective: This study assesses predictors for postoperative delirium (POD) and ICU stay durations in HFrEF patients undergoing CABG, focusing on ONCAB versus OPCAB surgical methods. Summary Background Data: In cardiac surgery, especially CABG, POD significantly impacts patient recovery and healthcare resource utilization. With varying incidences based on surgical techniques, this study provides an in-depth analysis of POD in the context of HFrEF patients, a group particularly susceptible to this complication. Methods: A retrospective analysis of 572 patients who underwent isolated CABG surgery with a preoperative ejection fraction under 40% was conducted at four German university hospitals. Patients were categorized into ONCAB and OPCAB groups for comparative analysis. Results: Age and Euro Score II were significant predictors of POD. The ONCAB group showed higher incidences of re-sternotomy (OR: 3.37), ECLS requirement (OR: 2.29), and AKI (OR: 1.49), whereas OPCAB was associated with a lower incidence of delirium. Statistical analysis indicated a significant difference in ICU stay durations between the two groups, influenced by surgical complexity and postoperative complications. Conclusions: This study underscores the importance of surgical technique in determining postoperative outcomes in HFrEF patients undergoing CABG. OPCAB may offer advantages in reducing POD incidence. These findings suggest the need for tailored surgical decisions and comprehensive care strategies to enhance patient recovery and optimize healthcare resources.

Dual-Time-Point Posttherapy 177Lu-PSMA-617 SPECT/CT Describes the Uptake Kinetics of mCRPC Lesions and Prognosticates Patients' Outcome.

177Lu-PSMA-617 is an effective therapeutic option in metastasized castration-resistant prostate cancer (mCRPC). However, some patients progress under treatment. We hypothesized that the tracer kinetics within the metastases may influence the therapy effectiveness and tested this hypothesis by analyzing uptake parameters on 2 consecutive posttherapy SPECT/CT scans. Methods: mCRPC patients treated with 177Lu-PSMA-617 and with available posttherapy SPECT/CT imaging (24 and 48 h after the first treatment) were enrolled retrospectively. Volumes of interest were defined on lymph node metastasis (LNM) and bone metastasis (BM) on both SPECT/CT scans. The reduction of the percentage injected dose (%IDred) between the 2 SPECT/CT scans was computed. We compared %IDred of responders (prostate-specific antigen drop ≥ 50% after 2 cycles of 177Lu-PSMA-617) and nonresponders. We tested the association of %IDred with progression-free survival and overall survival (OS) using a univariate Kaplan-Meier (KM) analysis and a multivariate Cox regression model. Results: Fifty-five patients (median age, 73 y; range, 54-87 y) were included. %IDred in LNM and BM was greater in nonresponders than in responders (for LNM, 36% in nonresponders [interquartile range (IQR), 26%-47%] vs. 24% in responders [IQR, 12%-33%] [P = 0.003]; for BM, 35% in nonresponders [IQR, 27%-52%] vs. 18% in responders [IQR, 15%-29%] [P = 0.002]). For progression-free survival, in KM analysis, greater %IDred in LNM (P = 0.008) and BM (P = 0.001) was associated with shorter survival, whereas in multivariate analysis, only %IDred in LNM was retained (P = 0.03). In univariate KM analysis of OS, greater %IDred in BM was associated with shorter survival (P = 0.002). In multivariate OS analysis, BM %IDred (P = 0.009) was retained. Conclusion: The 177Lu-PSMA-617 clearance rate from mCRPC metastases appears to be a relevant prognosticator of response and survival, with faster clearing possibly signaling a shorter radiopharmaceutical residence time and absorbed dose. Dual-time-point analysis appears to be a feasible and readily available approach to estimate the likelihood of response and patients' survival.

Deep learning-based scoring of tumour-infiltrating lymphocytes is prognostic in primary melanoma and predictive to PD-1 checkpoint inhibition in melanoma metastases.

BACKGROUND: Recent advances in digital pathology have enabled accurate and standardised enumeration of tumour-infiltrating lymphocytes (TILs). Here, we aim to evaluate TILs as a percentage electronic TIL score (eTILs) and investigate its prognostic and predictive relevance in cutaneous melanoma. METHODS: We included stage I to IV cutaneous melanoma patients and used hematoxylin-eosin-stained slides for TIL analysis. We assessed eTILs as a continuous and categorical variable using the published cut-off of 16.6% and applied Cox regression models to evaluate associations of eTILs with relapse-free, distant metastasis-free, and overall survival. We compared eTILs of the primaries with matched metastasis. Moreover, we assessed the predictive relevance of eTILs in therapy-naïve metastases according to the first-line therapy. FINDINGS: We analysed 321 primary cutaneous melanomas and 191 metastatic samples. In simple Cox regression, tumour thickness (p < 0.0001), presence of ulceration (p = 0.0001) and eTILs ≤16.6% (p = 0.0012) were found to be significant unfavourable prognostic factors for RFS. In multiple Cox regression, eTILs ≤16.6% (p = 0.0161) remained significant and downgraded the current staging. Lower eTILs in the primary tissue was associated with unfavourable relapse-free (p = 0.0014) and distant metastasis-free survival (p = 0.0056). In multiple Cox regression adjusted for tumour thickness and ulceration, eTILs as continuous remained significant (p = 0.019). When comparing TILs in primary tissue and corresponding metastasis of the same patient, eTILs in metastases was lower than in primary melanomas (p < 0.0001). In therapy-naïve metastases, an eTILs >12.2% was associated with longer progression-free survival (p = 0.037) and melanoma-specific survival (p = 0.0038) in patients treated with anti-PD-1-based immunotherapy. In multiple Cox regression, lactate dehydrogenase (p < 0.0001) and eTILs ≤12.2% (p = 0.0130) were significantly associated with unfavourable melanoma-specific survival. INTERPRETATION: Assessment of TILs is prognostic in primary melanoma samples, and the eTILs complements staging. In therapy-naïve metastases, eTILs ≤12.2% is predictive of unfavourable survival outcomes in patients receiving anti-PD-1-based therapy. FUNDING: See a detailed list of funding bodies in the Acknowledgements section at the end of the manuscript.

Early initiation of antibiotic therapy and short-term outcomes in preterm infants: a single-centre retrospective cohort analysis.

BACKGROUND: Sepsis is one of the most important complications in preterm infants. For this reason, many such infants receive antibiotics during their hospital stay. However, early antibiotic therapy has also been associated with adverse outcome. It is yet largely unclear if the time of onset of antibiotic therapy influences the outcome. We here investigated whether the timing of initiation of antibiotic therapy plays a role in the association between antibiotic exposure and short-term outcome. METHODS: Retrospective analysis of data from 1762 very low birthweight infants born in a German neonatal intensive care unit (NICU) between January 2004 and December 2021. RESULTS: Antibiotics were administered to 1214 of the 1762 (68.9%) infants. In 973 (55.2%) of the 1762 of infants, antibiotic therapy was initiated within the first two postnatal days. Only 548 (31.1%) infants did not have any antibiotic prescription during their stay in the NICU. Antibiotic exposure at every timepoint was associated with an increased risk of all short-term outcomes analysed in univariable analyses. In multivariable analyses, initiation of antibiotic therapy within the first two postnatal days and initiation between postnatal days 3 and 6 was independently associated with an increased risk of developing bronchopulmonary dysplasia (BPD) (OR 3.1 and 2.8), while later initiation of antibiotic therapy was not. CONCLUSION: Very early initiation of antibiotic therapy was associated with an increased risk of BPD. Due to the study design, no conclusions on causality can be drawn. If confirmed, our data suggest that an improved identification of infants at low risk of early-onset sepsis is needed to reduce antibiotic exposure.

Impacto del lugar de residencia en la supervivencia de los pacientes con trasplante renal. ¿Puede la telemedicina mejorar este desenlace? / How residence affects the survival of kidney transplant recipients, can it be improved by telemedicine?

Antecedente: el trasplante renal es el tratamiento de elección en la enfermedad crónica terminal. Un adecuado seguimiento en el postrasplante mejora la supervivencia del injerto y del paciente a largo plazo. Objetivo: comparar los desenlaces clínicos de la población trasplantada renal que vive en el área metropolitana de Medellín con los que residen por fuera de este lugar, con el fin de plantear un modelo de atención para el seguimiento por medio de la telemedicina. Métodos: estudio descriptivo, retrospectivo y de un único centro. Se determinó la tasa de supervivencia mediante las curvas de Kaplan-Meier. Resultados: durante el período 2005-2015 se realizaron 754 trasplantes, el 42 % vivía por fuera del área metropolitana. Al agrupar esta cohorte según el lugar de residencia, se observó que la supervivencia de los pacientes residentes en el área metropolitana a 1, 3 y 5 años fue del 96,8 %, 93,7 % y 91,8 %, respectivamente, en contraste con el 94,4 %, 90,3 % y 85,2 % de los del área rural. Esta diferencia fue estadísticamente significativa a favor de los que viven en Medellín (log-rank test p = 0,048; Hazard ratio = 1,68; IC 95 % 0,99-2,84, p = 0,052). Conclusión: la supervivencia fue inferior en los pacientes trasplantados renales que viven por fuera del área Metropolitana. Lo anterior motiva el desarrollo de un modelo de atención para estos pacientes mediado por la telemedicina para facilitar el acceso al seguimiento postrasplante.

Background: Kidney transplantation is the treatment of choice for end-stage renal disease. An adequate post-transplant follow-up improves the graft and patient's long-term survival. Objective: The aim of this study was to compare the outcomes of kidney transplant patients who live in the Medellin metropolitan area with those who live outside this area, to propose a model for follow-up care through telemedicine. Methods: Descriptive, retrospective and one-center study. Kaplan-Meier method was used to determine the survival rate. Results: Between 2005 and 2015, 742 patients were transplanted, 42% of whom lived outside the metropolitan area. The survival rates after 1, 3 and 5 years of treatment in patients in the metropolitan area of Medellín compared to those outside were 96.8%, 93.7% y 91.8% and 94.4%, 90.3% y 85.2% respectively, with statistically significant differences (Log-rank test p=0.048, Hazard ratio 1.68, IC 95% 0.99-2.84, p=0.052). Conclusion: The survival rate was lower in kidney transplant patients living outside the urban area. These findings motivate the development of a telemedicine project to facilitate the follow-up of these patients after a kidney transplantation.

Diagnóstico de amiloidosis renal AA mediante espectrometría de masas en un paciente con proceso inflamatorio crónico grave abdominal

Introducción la amiloidosis es una enfermedad rara, producto del plegamiento y depósito normal de proteínas en tejidos y órganos. Esta enfermedad puede tener un compromiso renal que se manifiesta con síndrome nefrótico y deterioro de la función renal y su etiología puede estar asociada a amiloidosis con compromiso sistémico, siendo la amiloidosis AL y la amiloidosis AA las más frecuentes, esta última está asociada a inflamación crónica grave de origen infecciosa o autoinmune. Para el diagnóstico es fundamental el estudio sistémico multidisciplinario (hematológico, cardiaco, autoinmune, infeccioso y neoplásico), y cuando hay compromiso renal: la biopsia con estudio completo de microscopía de luz, tinciones especiales incluyendo rojo congo, inmunofluorescencia y microscopía electrónica. Cuando no se logra establecer la causa, la espectrometría de masas es una ayuda crucial para el diagnóstico específico. Objetivo se presenta el caso de un paciente con un proceso inflamatorio crónico grave abdominal que evolucionó a síndrome nefrótico por amiloidosis AA, donde la espectrometría de masas ayudó a aclarar el diagnóstico. Presentación del caso se presenta el caso de un paciente con un proceso inflamatorio crónico grave abdominal que evolucionó a síndrome nefrótico por amiloidosis AA, donde la espectrometría de masas ayudó a aclarar el diagnóstico Discusión y conclusiones se considera que la espectrometría de masas es un estudio diagnóstico muy importante para establecer el diagnóstico etiológico de la amiloidosis cuando otros métodos no han logrado establecerlo.

Introduction Amyloidosis is a rare disease, resulting from the accumulation and deposition of insoluble proteins in tissues or organs. This disease may involve the kidney, resulting in nephrotic syndrome and renal failure. The amyloidosis has been associated with systemic involvement, with AL amyloidosis and AA amyloidosis being the most common. The last is associated with various inflammatory disorders as chronic infections and autoimmune diseases. A multidisciplinary approach is required to the diagnosis (hematologic, cardiac, autoimmune, infectious, neoplastic) and in cases of renal involvement, a kidney biopsy with complete study of light microscopy, special stains including congo red, immunofluorescence, electron microscopy is essential for diagnosis. In cases where the cause cannot be stablished, mass spectrometry is practical tool to the identification of the correct type of amyloidosis. Purpose Here, we present a patient with a chronic and severe abdominal inflammatory process that progressed to a nephrotic syndrome due to AA amyloidosis, in which mass spectrometry helped to clarify the diagnosis. Case presentation Here, we present a patient with a chronic and severe abdominal inflammatory process that progressed to a nephrotic syndrome due to AA amyloidosis, in which mass spectrometry helped to clarify the diagnosis Discussion and conclusion Mass spectrometry is considered a useful diagnostic test to confirm the etiology of amyloidosis, especially if other methods are insufficient to establish it.

Multiparametric Classification of Non-Muscle Invasive Papillary Urothelial Neoplasms: Combining Morphological, Phenotypical, and Molecular Features for Improved Risk Stratification.

Diagnosis and grading of non-invasive papillary urothelial tumors according to the current WHO classification poses some challenges for pathologists. The diagnostic reproducibility of separating low-grade and high-grade lesions is low, which impacts their clinical management. Whereas papillary urothelial neoplasms with low malignant potential (PUN-LMP) and low-grade papillary non-invasive carcinoma (LG-PUC) are comparable and show frequent local recurrence but rarely metastasize, high-grade papillary non-invasive carcinoma (HG-PUC) has a poor prognosis. The main objective of this work is to develop a multiparametric classification to unambiguously distinguish low-grade and high-grade tumors, considering immunohistochemical stains for p53, FGFR3, CK20, MIB-1, p16, p21 and p-HH3, and pathogenic mutations in TP53, FGFR3, TP53, ERCC2, PIK3CA, PTEN and STAG2. We reviewed and analyzed the clinical and histological data of 45 patients with a consensus diagnosis of PUN-LMP (n = 8), non-invasive LG-PUC (n = 23), and HG-PUC (n = 14). The proliferation index and mitotic count assessed with MIB-1 and P-HH3 staining, respectively correlated with grading and clinical behavior. Targeted sequencing confirmed frequent FGFR3 mutations in non-invasive papillary tumors and identified mutations in TP53 as high-risk. Cluster analysis of the different immunohistochemical and molecular parameters allowed a clear separation in two different clusters: cluster 1 corresponding to PUN-LMP and LG-PUC (low MIB-1 and mitotic count/FGFR3 and STAG2 mutations) and cluster 2, HG-PUC (high MIB-1 and mitosis count/CK20 +++ expression, FGFR3 WT and TP53 mutation). Further analysis is required to validate and analyze the reproducibility of these clusters and their biological and clinical implication.

Penile necrosis secondary to uremic calciphylaxis / Necrosis peneana secundaria a calcifilaxis urémica

Abstract The advanced stages of chronic kidney disease are associated with mineral and bone metabolism disorders, which increase the risk of serious complications such as uremic calciphylaxis. Below we present the case of a 65-year-old male patient with multiple comorbidities, including stage 5 chronic kidney disease with long-term hemodialysis treatment, who presented refractory secondary hyperparathyroidism complicated by penile necrosis secondary to uremic calciphylaxis. We believe this case may be useful in sensitizing the medical community on the seriousness of uremic calciphylaxis, emphasizing the importance of prevention and early diagnosis before complications such as necrosis occur. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2224).

Resumen Los estadios avanzados de la enfermedad renal crónica se asocian a alteraciones en el metabolismo mineral óseo, lo cual aumenta el riesgo de complicaciones graves como la calcifilaxis urémica. A continuación se presenta el caso de un paciente masculino de 65 años, con múltiples comorbilidades, entre ellas enfermedad renal crónica estadio 5 en terapia de hemodiálisis durante largo tiempo, quien presentó hiperparatiroidismo secundario de difícil manejo y se complicó con necrosis peneana secundaria a calcifilaxis urémica. Se considera que este caso puede ser útil para sensibilizar a la comunidad médica sobre la gravedad de la calcifilaxis urémica por lo cual es muy importante la prevención y realización de un diagnóstico temprano antes de que se produzcan complicaciones como la necrosis. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2224).

Trasplante renal en pacientes con infección por el virus de la inmunodeficiencia humana: revisión de la literatura / Renal transplantation in patients with human immunodeficiency virus infection: a literature review

Resumen El trasplante renal es el tratamiento de elección en la enfermedad renal crónica terminal porque mejora la calidad de vida y la supervivencia de los pacientes al compararlo con la diálisis. Sin embargo, para mantener un injerto funcional y evitar el rechazo es necesario el uso de inmunosupresión potente durante toda la vida del injerto, lo cual puede tener como complicaciones una mayor susceptibilidad a presentar infecciones, desarrollo de cáncer, alteraciones metabólicas y problemas cardiovasculares. Los pacientes infectados con el virus de la inmunodeficiencia humana tienen alto riesgo de desarrollar enfermedad renal crónica terminal por múltiples causas. En el siglo pasado, el trasplante renal se consideraba contraindicado para estos pacientes. No obstante, hoy en día el trasplante renal se considera una opción terapéutica para pacientes adecuadamente seleccionados y con protocolos de manejo bien establecidos. Reportándose supervivencia reportadas del injerto y del paciente a tres años de 88,2 % y 82,6 % respectivamente. Este artículo de revisión tiene como objetivo revisar la experiencia mundial existente en el manejo de los pacientes trasplantados renal con infección por VIH.

Summary Kidney transplantation is the recommended treatment for end-stage chronic kidney disease, improving patients' quality of life and survival compared to dialysis. Nevertheless, to keep a functional graft and avoid rejection, strong immunosuppression is required during the graft's lifetime, which can lead to complications such as increased susceptibility to infections, development of cancer, metabolic changes and cardiovascular problems. Patients infected with the human immunodeficiency virus are at high risk of developing end-stage renal disease. Previous this century, kidney transplantation was considered contraindicated for these patients group. However nowadays, kidney transplantation is a therapeutic option for well-selected patients and with well-established treatment protocols. Several studies reported a three-year graft survival rate of 88,2% and patient survival of 82,6%. In this article, we present an overview of the worldwide experience with the treatment of kidney transplant patients with HIV infection.

Enfermedad renal crónica de las comunidades agrícolas, una revisión de la literatura / Chronic Kidney Disease in Agricultural Communities, review of the literature

Resumen La enfermedad renal crónica (ERC) se define como la alteración funcional o estructural progresiva de los riñones que persiste por 3 meses o más. Esta enfermedad afecta el 10 al 15 % de la población mundial, siendo la diabetes mellitus, la hipertensión arterial, las glomerulopatías primarias y las enfermedades genéticas las etiologías más frecuentemente asociadas. Sin embargo, en los países pobres se reportan otras enfermedades causantes de la ERC; entre ellas la nefropatía mesoamericana (NM). La NM se presenta principalmente en la población masculina joven, lo cual lleva a pérdida de la vida laboral productiva. En Colombia hay una alta prevalencia de ERC con etiología no estudiada (mal llamada desconocida) y hay pocas investigaciones de la ERC en las comunidades agrícolas. Teniendo en cuenta que la población campesina de Colombia se expone a noxas climáticas y laborales similares a Mesoamérica, es posible que esta nefropatía también sea una causa de ERC en nuestra población. El presente artículo hace una revisión de la ERC de las comunidades agrícolas, con el fin de sensibilizar el personal de salud en la importancia de la búsqueda de esta enfermedad en la población vulnerable, lo cual podría impactar de una forma positiva en la salud de los agricultores y campesinos.

Summary Chronic kidney disease (CKD) is defined as an abnormality of the kidney structure or function for ≥ 3 months. This disease affects 10% to 15% of the world's population, with diabetes, arterial hypertension, primary glomerulopathies and genetic disorders being the most common etiologies associated with this disease worldwide. Nevertheless, in low-income countries, other diseases causing CKD are also reported; among them, Mesoamerican nephropathy, which is a common cause of CKD in Mesoamerica, especially in the young male population, leading to loss of productive working capacity. In Colombia, the prevalence of CKD with unknown etiology is high and there are few studies on chronic kidney disease in agricultural communities, given that the agricultural population in Colombia is exposed to harmful climatic and occupational agents similar to those in Mesoamerica, it is possible that this nephropathy is also a cause of CKD in our population. This article provides an overview of CKD in agricultural communities to sensitize health workers to the importance of screening for this disease in vulnerable populations, which could have a positive impact on the health of farmers.

Occurrence and Severity of Venous Air Embolism During Neurosurgical Procedures: Semisitting Versus Supine Position.

BACKGROUND: At our institution, patients undergoing neurosurgical procedures in the posterior cranial fossa are placed either in the semisitting or in the supine position. The major risk of the semisitting positioning is a venous air embolism (VAE), which may, however, also occur in the supine position. METHODS: In a prospective single-center study with 137 patients, we evaluated the occurrence of VAEs in patients in the supine and in the semisitting position during the period from January 2014 until April 2015. All patients were monitored for VAE by the use of a transesophageal echocardiography (TEE). RESULTS: In total, 50% of the patients experienced a VAE (56% of these patients underwent surgery in the semisitting and 11% in the supine position). In total, 86% of the VAEs were detected by the use of a TEE and did not lead to any changes in the end-expiratory CO2. We only observed VAEs with a decrease in end-expiratory CO2 in the semisitting position. However, none of the patients had any hemodynamic changes due to the VAE. CONCLUSIONS: The semisitting position with TEE monitoring and a standardized protocol is a safe and advantageous technique, taking account of a significant rate of VAEs. VAEs also occur in the supine position, but less frequently.

Development and internal validation of the Comprehensive ALPPS Preoperative Risk Assessment (CAPRA) score: is the patient suitable for Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS)?

Background: Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is not always reliable with currently available scores, particularly in patients with primary liver tumor. This study aims to (I) to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and (II) to create a score predicting 90-day mortality preoperatively. Methods: Thirteen high-volume centers participated in this retrospective multicentric study. A risk analysis based on patient characteristics, underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment (CAPRA) score. A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index (CCI), the age-adjusted CCI (aCCI), the ALPPS risk score before Stage 1 (ALPPS-RS1) and Stage 2 (ALPPS-RS2). The model was internally validated applying bootstrapping. Results: A total of 451 patients were included. Mortality was 14.4%. The CAPRA score is calculated based on the following formula: (0.1 × age) - (2 × BSA) + 1 (in the presence of primary liver tumor) + 1 (in the presence of severe cardiovascular disease) + 2 (in the presence of moderate or severe diabetes) + 2 (in the presence of renal disease) + 2 (if classic ALPPS is planned). The predictive ability was 0.837 for the CAPRA score, 0.443 for CCI, 0.519 for aCCI, 0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2. After 1,000 cycles of bootstrapping the C statistic was 0.793. The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70. Conclusions: Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure. By assessing the patient's preoperative condition in relation to ALPPS, the CAPRA score has a very good ability to predict postoperative mortality.

Espondiloartropatía destructiva no infecciosa en un paciente en hemodiálisis / Destructive noninfectious spondyloarthropathy in a hemodialysis patient

Resumen La espondiloartropatía destructiva es una patología osteoarticular presente en algunos pacientes con enfermedad crónica que puede afectar varios niveles de la columna vertebral y puede ser asintomática, generar dolor o causar complicaciones que ponen en peligro la integridad de la médula espinal y/o la vida. Presentamos el caso de un hombre de 70 años con enfermedad renal crónica terminal en hemodiálisis quien consultó por dolor dorsal y paraplejia, en quien se diagnosticó espondiloartropatía destructiva no infecciosa por imágenes y estudio histopatológico. Este caso nos muestra la importancia de pensar en esta patología y la necesidad de un enfoque multidisciplinario en el diagnóstico y manejo. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2193).

Abstract Destructive spondyloarthropathy is a bone and joint disease which presents in some patients with chronic illnesses and may affect various levels of the spinal column. It may be asymptomatic, cause pain, or produce spinal cord and/or life-endangering complications. We present the case of a 70-year-old man with end-stage renal disease on hemodialysis who consulted due to back pain and paraplegia. He was diagnosed with destructive noninfectious spondyloarthropathy through imaging and histopathological studies. This case shows us the importance of considering this disease and the need for a multidisciplinary approach in its diagnosis and management. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2193).

Left ventricular assist device implantation causes platelet dysfunction and proinflammatory platelet-neutrophil interaction.

Blood flow through left ventricular assist devices (LVAD) may induce activation and dysfunction of platelets. Dysfunctional platelets cause coagulation disturbances and form platelet-neutrophil conjugates (PNC), which contribute to inflammatory tissue damage. This prospective observational cohort study investigated patients, who underwent implantation of a LVAD (either HeartMate II (HM II) (n = 7) or HeartMate 3 (HM 3) (n = 6)) and as control patients undergoing coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) (n = 10). We performed platelet and leukocyte flow cytometry, analysis of platelet activation markers, and platelet aggregometry. Platelet CD42b expression was reduced at baseline and perioperatively in HM II/3 compared to CABG/AVR patients. After surgery the platelet activation marker ß-thromboglobulin and platelet microparticles increased in all groups while platelet aggregation decreased. Platelet aggregation was more significantly impaired in LVAD compared to CABG/AVR patients. PNC were higher in HM II compared to HM 3 patients. We conclude that LVAD implantation is associated with platelet dysfunction and proinflammatory platelet-leukocyte binding. These changes are less pronounced in patients treated with the newer generation LVAD HM 3. Future research should identify device-specific LVAD features, which are associated with the least amount of platelet activation to further improve LVAD therapy.

Nephrotic syndrome as a manifestation of thrombotic microangiopathy due to long-term use of sunitinib.

Nephrotic syndrome in patients with cancer may be related to the primary malignancy or chemotherapeutic therapy. Solid organ cancers may cause membranous glomerulonephritis which is manifested by nephrotic syndrome; other less common histologic presentations include focal and segmental glomerulosclerosis and minimal change disease. In addition, chemotherapy agents may cause renal toxicity by affecting the small blood vessels, glomeruli, tubules, and interstitium. Tyrosine kinase inhibitors such as sunitinib may cause endothelial and podocyte damage leading to thrombotic microangiopathy affecting only the kidney and manifested by proteinuria and hypertension. We report a case of an elderly man with gastrointestinal stromal tumor (GIST) on treatment with sunitinib who had as a complication a thrombotic microangiopathy manifested with nephrotic syndrome and a hypertension of difficult control, which was finally controlled by stopping this drug but had a fatal outcome due to its malignancy.

Early Tumor Size Reduction of at least 10% at the First Follow-Up Computed Tomography Can Predict Survival in the Setting of Advanced Melanoma and Immunotherapy.

RATIONALE AND OBJECTIVES: Early tumor size reduction (TSR) has been explored as a prognostic factor for survival in patients with advanced melanoma in clinical trials. The purpose of this analysis is to validate, in a routine clinical milieu, the predictive capacity of TSR by 10% for overall survival (OS) and progression-free survival (PFS) and to compare its predictive performance with the RECIST 1.1 criteria. MATERIALS AND METHODS: This retrospective study was approved by the local ethics committee. A total of 152 patients with both CT before immunotherapy initiation and at first response evaluation after immunotherapy initiation were included. Prior to statistical analysis, treatment response was trichotomized as follows: Complete response and/or partial response, stable disease and progressive disease. Furthermore, response was dichotomized regarding TSR (TSR ≥ 10% and TSR < 10%). Kaplan-Meier survival estimates, Cox regression and Harrel's concordance index (C-index) were computed for prediction of overall survival and progression-free survival. RESULTS: Tumor size reduction by at least 10% significantly differentiated between patients with increased survival from the ones with decreased survival (median OS: TSR ≥ 10%: 2137 days vs. TSR < 10%: 263 days) (p < 0.001) (median PFS: TSR ≥ 10%: 590 days vs. TSR < 10%: 11 days) (p < 0.001). RECIST 1.1. criteria had a slightly higher C-index for overall survival reflecting a slight superior predictive capacity (RECIST: 0.69 vs TSR: 0.64) but a similar predictive capacity regarding progression-free survival (both: 0. 63). CONCLUSION: Early tumor size reduction serves as a simple-to-use metric which can be implemented on the first follow-up CT. Tumor size reduction by at least 10% can be considered an additional biomarker predictive of overall survival and progression-free survival in routine clinical care and not only in the context of clinical trials in patients with advanced melanoma undergoing immunotherapy. Nevertheless, RECIST-based criteria should remain the main tool of treatment response assessment until results of prospective studies validating the TSR method are available.

Off-pump coronary artery bypass grafting for patients with severely reduced ventricular function-A justified strategy?

BACKGROUND AND AIM: Low ejection fraction (EF) has been identified as a main risk factor for perioperative complications and mortality after coronary artery bypass grafting (CABG). The purpose of this study was to compare the efficacy and early as well as midterm outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) surgery in patients with reduced EF. METHODS: We performed a retrospective review of patient demographics, preoperative risk factors, operative and postoperative outcomes of patients with left ventricular EF (LV-EF) ≤35%, who underwent CABG at our institution between January 2015 and December 2017. Propensity score and multivariate logistic regression analysis were used to compare risk adjusted outcomes between groups. RESULTS: Overall, 111 consecutive CABG-patients with LV-EF ≤ 35% underwent either ONCAB (46 patients, 41.4%) or OPCAB surgery (65 patients, 58.6%). There was no difference in early mortality (5% vs. 7.5%, p = .64) between groups. After propensity score matching, OPCAB-patients required significantly less re-sternotomies for bleeding (20% vs. 2.5%, p = .03) and consequently received significantly less blood transfusions (57.5% vs. 32.5%, p = .03). Fewer OPCAB-patients experienced low cardiac output syndrome (22.5% vs. 42.5%, p = .06) and suffered from postoperative delirium (22.5% vs. 42.5%, p = .06). There were no differences in completeness of revascularization between groups (median 1 (1.0-1.33; 1.0-1.33) OPCAB versus median 1 (1-1.33; 0.67-2) ONCAB, p = .95). Survival after 6 months, one year and three years was similar for ONCAB- and OPCAB-patients (ONCAB 92.3%, 89.4%, and 89.4% vs. OPCAB 89.8%, 85.7%, and 82.1%; p = .403). More ONCAB-patients needed a coronary re-intervention during follow-up (8.6% vs. 2.3%, p = .402). CONCLUSION: OPCAB-surgery is a safe and effective option for patients with reduced EF. Furthermore, it does not come at the expense of less complete revascularization or increased coronary re-intervention during early follow-up.

Association between Immune-Related Adverse Events and Survival in 319 Stage IV Melanoma Patients Treated with PD-1-Based Immunotherapy: An Approach Based on Clinical Chemistry.

(1) Background: Immune checkpoint inhibitors have improved the prognosis of patients with advanced melanoma. Published data suggested that the objective response rates appear to be superior in patients who developed immune-related adverse events (irAEs). (2) The primary aim of this cohort study was to evaluate the association between irAEs and disease control rate in patients with stage IV melanoma treated with first-line PD-1-based immunotherapy. (3) Among 319 patients, 53% experienced at least one irAE. A higher percentage of patients with irAEs had disease control compared to those without irAEs (69.8% vs. 49.3%). In multivariate analysis, development of grade 3 and 4 irAEs was significantly associated with a protective effect for the outcome primary resistance (OR: 0.40 95% CI 0.23-0.70, p = 0.001). The presence of any grade irAEs was significantly associated with longer OS (irAEs grade 1-2 HRadj: 0.61 95% CI: 0.4-0.93, p = 0.02, irAEs grade 3-4 HRadj: 0.55 95% CI 0.31-0.99, p = 0.04), but not with PFS (irAEs grade 1-2 HRadj: 1.21 95% CI: 0.91-1.79, p = 0.16, irAEs grade 3-4 HRadj: 1.14 95% CI 0.83-2.02, p = 0.24). (4) The presence of irAEs with laboratorial expression is positively associated with response and OS, suggesting that irAEs might be a predictive factor in this setting.

Modalidad previa de diálisis y su influencia en los resultados del trasplante renal / Impact of predialysis therapy on kidney transplant outcomes

Resumen Introducción: el trasplante renal es el tratamiento de elección para los pacientes con enfermedad renal crónica terminal; sin embargo, un trasplante renal anticipado no siempre es posible y muchos pacientes requieren algún tipo de terapia de reemplazo renal previa al trasplante. Objetivo: este estudio tiene como objetivo evaluar los desenlaces a corto y largo plazo, post-trasplante renal, de acuerdo con la modalidad de diálisis previa al trasplante. Métodos: estudio de tipo cohorte retrospectiva. Se incluyeron pacientes mayores de 18 años que recibieron un trasplante renal durante 2005-2018. Inicialmente se realizó estadística descriptiva y posteriormente se realizó análisis multivariado mediante un modelo de riesgos proporcionales de Cox, con el objetivo de evaluar la relación entre la supervivencia del paciente y del injerto y la necesidad de diálisis previa al trasplante. Se evaluó, además, la tasa de filtración glomerular durante los primeros dos años del trasplante renal. Resultados: durante 2005-2018 se realizaron 925 trasplantes renales, 289 estaban en diálisis peritoneal, 439 en hemodiálisis y 197 no estaban en diálisis. La supervivencia del paciente a 6, 12, 24, 48 y 60 meses posterior al trasplante renal fue de 97,5 %, 96,7 %, 96,0 %, 93,7 % y 92,3 %, respectivamente, y del injerto fue de 94,5 %, 92,9 %, 90,5 %, 84,8 %, 81,1 %, también respectivamente, sin encontrar diferencia estadísticamente significativa entre los que tuvieron diálisis peritoneal vs. hemodiálisis (p = 0,402, p = 0,180), tampoco se encontraron diferencias significativas en el análisis multivariado. El 8,1 % de los pacientes presentó rechazo agudo en el primer año post trasplante y el 13,2 % durante todo el seguimiento, sin encontrarse diferencias significativas entre los que habían tenido diálisis peritoneal vs. hemodiálisis. No se encontraron diferencias en la TFG. Conclusiones: no se encontraron diferencias estadísticamente significativas en los desenlaces duros a corto y largo plazo, según la modalidad de diálisis pretrasplante.

Abstract Introduction: kidney transplantation is the standard treatment option for patients with end-stage chronic kidney disease. However, early kidney transplantation is not always possible, and many patients require renal replacement therapy. This study aims to evaluate the short and long-term outcomes after kidney transplantation in patients undergoing dialysis therapy before transplantation. Methods: a retrospective cohort of renal transplant patients older than 18 years of age were evaluated during the years 2005-2018. A descriptive analysis was performed. A proportional Cox-Hazard model was used to evaluate the relationship between patient and transplant survival and pre-transplant dialysis. An analysis of variance was used to compare the glomerular filtration rate during the first two years after transplantation. Results: between 2005-2018, 925 kidney transplants were performed, of which 289 required peritoneal dialysis, 439 haemodialysis and 197 did not require dialysis. Patient and transplant survival rates at 6, 12, 24, 48, 60 months after kidney transplantation were 97.5%, 96.7%, 96.0%, 93.7%, 92.3%, 94.5%, 92.9%, 90.5%, 84.8%, 81.1%. No statistically significant difference was found between peritoneal dialysis patients and hemodialysis patients (p=0.402, p=0.180). Acute rejection occurred in 8.1% of patients in the first year after transplantation and in 13.2% during the entire follow-up. Glomerular filtration rate values were similar in patients with and those without pre-transplant dialysis Conclusions: there were no significant statistical differences in short and long-term outcomes among patients undergoing pre-transplant dialysis vs. no.