Uric acid and acute kidney injury in high-risk patients for developing acute kidney injury undergoing cardiac surgery: A prospective multicenter study.

PURPOSE: It is unclear whether preoperative serum uric acid (SUA) elevation may play a role in the development of acute kidney injury (AKI) associated with cardiac surgery (CSA-AKI). We conducted a cohort study to evaluate the influence of preoperative hyperuricemia on AKI in patients at high risk for developing SC-AKI. DESIGN: Multicenter prospective international cohort study. SETTING: Fourteen university hospitals in Spain and the United Kingdom. PARTICIPANTS: We studied 261 consecutive patients at high risk of developing CSA-AKI, according to a Cleveland score ≥ 4 points, from July to December 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: AKIN criteria were used for the definition of AKI. Multivariable logistic regression models and propensity score-matched pairwise analysis were used to determine the adjusted association between preoperative hyperuricemia (≥7 mg/dL) and AKI. Elevated preoperative AUS (≥7 mg/dL) was present in 190 patients (72.8%), whereas CSA-AKI occurred in 145 patients (55.5%). In multivariable logistic regression models, hyperuricemia was not associated with a significantly increased risk of AKI (adjusted Odds Ratio [OR]: 1.58; 95% confidence interval [CI]: 0.81-3; P = .17). In propensity score-matched analysis of 140 patients, the hyperuricemia group experienced similar adjusted odds of AKI (OR 1.05, 95%CI 0.93-1.19, P = .37). CONCLUSIONS: Hyperuricemia was not associated with an increased risk of AKI in this cohort of patients undergoing cardiac surgery at high risk of developing CSA-AKI.

Epidemiology of fungal infection in COVID 19 in Spain during 2020 and 2021: a nationwide study.

We realize a nationwide population-based retrospective study to analyze the characteristics and risk factors of fungal co-infections in COVID-19 hospitalized patients as well as describe their causative agents in the Spanish population in 2020 and 2021. Data were obtained from records in the Minimum Basic Data Set of the National Surveillance System for Hospital Data in Spain, provided by the Ministry of Health, and annually published with two years lag. The assessment of the risk associated with the development of healthcare-associated fungal co-infections was assessed using an adjusted logistic regression model. The incidence of fungal co-infection in COVID-19 hospitalized patients was 1.41%. The main risk factors associated were surgery, sepsis, age, male gender, obesity, and COPD. Co-infection was associated with worse outcomes including higher in-hospital and in ICU mortality, and higher length of stay. Candida spp. and Aspergillus spp. were the microorganisms more frequent. This is the first study analyzing fungal coinfection at a national level in hospitalized patients with COVID-19 in Spanish population and one of the few studies available that demonstrate that surgery was an independent risk factor of Aspergillosis coinfection in COVID-19 patients.

Endothelial dysfunction is an early indicator of sepsis and neutrophil degranulation of septic shock in surgical patients.

BACKGROUND: Stratification of the severity of infection is currently based on the Sequential Organ Failure Assessment (SOFA) score, which is difficult to calculate outside the ICU. Biomarkers could help to stratify the severity of infection in surgical patients. METHODS: Levels of ten biomarkers indicating endothelial dysfunction, 22 indicating emergency granulopoiesis, and six denoting neutrophil degranulation were compared in three groups of patients in the first 12 h after diagnosis at three Spanish hospitals. RESULTS: There were 100 patients with infection, 95 with sepsis and 57 with septic shock. Seven biomarkers indicating endothelial dysfunction (mid-regional proadrenomedullin (MR-ProADM), syndecan 1, thrombomodulin, angiopoietin 2, endothelial cell-specific molecule 1, vascular cell adhesion molecule 1 and E-selectin) had stronger associations with sepsis than infection alone. MR-ProADM had the highest odds ratio (OR) in multivariable analysis (OR 11·53, 95 per cent c.i. 4·15 to 32·08; P = 0·006) and the best area under the curve (AUC) for detecting sepsis (0·86, 95 per cent c.i. 0·80 to 0·91; P < 0·001). In a comparison of sepsis with septic shock, two biomarkers of neutrophil degranulation, proteinase 3 (OR 8·09, 1·34 to 48·91; P = 0·028) and lipocalin 2 (OR 6·62, 2·47 to 17·77; P = 0·002), had the strongest association with septic shock, but lipocalin 2 exhibited the highest AUC (0·81, 0·73 to 0·90; P < 0·001). CONCLUSION: MR-ProADM and lipocalin 2 could be alternatives to the SOFA score in the detection of sepsis and septic shock respectively in surgical patients with infection.

ANTECEDENTES: La estratificación de la gravedad de una infección se basa actualmente en la puntuación SOFA (Sequential Organ Failure Assessment), que es difícil de calcular fuera de la unidad de cuidados intensivos. Los biomarcadores podrían ayudar a estratificar la gravedad de la infección en pacientes quirúrgicos. MÉTODOS: Se compararon las concentraciones de 10 biomarcadores que denotan disfunción endotelial, 22 que indican granulopoyesis de emergencia y 6 que expresan la degranulación de neutrófilos en tres grupos de pacientes de tres hospitales españoles (100 con infección, 95 con sepsis y 57 con shock séptico) en las primeras doce horas después del diagnóstico. RESULTADOS: Siete biomarcadores que expresan disfunción endotelial (proadrenomedulina, sindecan-1, trombomodulina, angiopoyetina-2, endocan-1, molécula de adhesión endotelial 1 y E-selectina) mostraron una fuerte asociación con la sepsis en comparación con la infección aislada. La proadrenomedulina presentó el valor más alto de la razón de oportunidades (odds ratio, OR) en el análisis multivariable (OR 11,53, i.c. del 95% 4,15-32,08, P = 0,006) y la mejor área bajo la curva para detectar sepsis (AUC 0,86, i.c. del 95% 0,80-0,91, P < 0,001). En la comparación entre sepsis y shock séptico, los biomarcadores que mostraron la asociación más estrecha con el shock séptico fueron dos biomarcadores de degranulación de neutrófilos (proteinasa-3 y lipocalina-2) (OR 8,09, i.c. del 9% 1,34-48,91, P = 0,028; OR 6.62, i.c. del 95% 2,47-17,77, P = 0,002), pero la lipocalina-2 presentó la mejor AUC (0,81, i.c. del 95% 0,73-0,90, P < 0,001). CONCLUSIÓN: la proadrenomedulina y la lipocalina-2 podrían representar alternativas a la puntuación SOFA para detectar sepsis y shock séptico en pacientes quirúrgicos con infección.

Ability to predict the development of surgical site infection in cardiac surgery using the Australian Clinical Risk Index versus the National Nosocomial Infections Surveillance-derived Risk Index.

Surgical site infection (SSI) is a major infectious complication that increases mortality, morbidity, and healthcare costs. There are scores attempting to classify patients for calculating SSI risk. Our objectives were to validate the Australian Clinical Risk Index (ACRI) in a European population after cardiac surgery, comparing it against the National Nosocomial Infections Surveillance-derived risk index (NNIS) and analyzing the predictive power of ACRI for SSI in valvular patients. All the patients that who underwent cardiac surgery in a tertiary university hospital between 2011 and 2015 were analyzed. The patients were divided into valvular and coronary groups, excluding mixed patients. The ACRI score was validated in both groups and its ability to predict SSI was compared to the NNIS risk index. We analyzed 1,657 procedures. In the valvular patient group (n: 1119), a correlation between the ACRI score and SSI development (p < 0.05) was found; there was no such correlation with the NNIS index. The area under the receiver-operating characteristic curve (AUC) was 0.64 (confidence interval [CI] 95%, 0.5-0.7) for ACRI and 0.62 (95% CI, 0.5-0.7) for NNIS. In the coronary group (n: 281), there was a correlation between ACRI and SSI but no between NNIS and SSI. The ACRI AUC was 0.70 (95% CI, 0.5-0.8) and the NNIS AUC was 0.60 (95% CI, 0.4-0.7). The ACRI score has insufficient predictive power, although it predicts SSI development better than the NNIS index, fundamentally in coronary artery bypass grafting (CABG). Further studies analyzing determining factors are needed.

Uterine sarcoma vs adenocarcinoma: can MRI distinguish between them? / Sarcoma uterino frente a adenocarcinoma: ¿es posible distinguirlos mediante resonancia magnética?

OBJECTIVE: To analyze the MRI characteristics of uterine sarcomas (mainly carcinosarcomas) and to compare them with those of adenocarcinomas to define the findings that would be useful for the differential diagnosis. MATERIALS AND METHODS: We retrospectively reviewed the MRI studies of 13 patients with histologically diagnosed uterine sarcoma. We analyzed tumor size, signal in T2-weighted, unenhanced and gadolinium-enhanced T1-weighted, and diffusion-weighted sequences. We compared the data obtained with those of another series of 30 consecutive cases of adenocarcinomas studied with MRI. RESULTS: The sarcomas (> 9cm in 77% of cases) were considerably larger than the adenocarcinomas (p<0.001). There were no differences in FIGO staging by MRI or surgery: both tumor types were diagnosed in early stages. The signal intensity in T2-weighted images differed significantly between the two tumor types: all the sarcomas were heterogeneous and predominantly hyperintense with respect to the myometrium in T2-weighted sequences (p<0.001). In postcontrast studies, all the sarcomas showed enhancement greater than or equal to the myometrium; this finding was significantly different from the adenocarcinomas (p<0.001). In diffusion-weighted sequences, we found no significant differences in ADC values in the areas with greatest restriction, but the ADC map was more heterogeneous in the sarcomas. CONCLUSION: Uterine sarcomas do not have specific characteristics on MRI, but some findings can indicate the diagnosis. In our study, we found significant differences between sarcomas and adenocarcinomas. Sarcomas were larger, had more hyperintense and heterogeneous signal intensity in T2-weighted sequences, and enhanced more than or at least as much as the myometrium.

Angiogenic therapy for cardiac repair based on protein delivery systems.

Cardiovascular diseases remain the first cause of morbidity and mortality in the developed countries and are a major problem not only in the western nations but also in developing countries. Current standard approaches for treating patients with ischemic heart disease include angioplasty or bypass surgery. However, a large number of patients cannot be treated using these procedures. Novel curative approaches under investigation include gene, cell, and protein therapy. This review focuses on potential growth factors for cardiac repair. The role of these growth factors in the angiogenic process and the therapeutic implications are reviewed. Issues including aspects of growth factor delivery are presented in relation to protein stability, dosage, routes, and safety matters. Finally, different approaches for controlled growth factor delivery are discussed as novel protein delivery platforms for cardiac regeneration.

Effects of simvastatin on systemic inflammatory responses after cardiopulmonary bypass.

AIM: Cardiopulmonary bypass is associated with a complex systemic inflammatory response and the extent of their increase has been correlated with the development of postoperative complications. Recent studies suggest that treatment with statins is associated with a significant and marked decrease in inflammation-associated variables such as cytokines. Therefore, we investigated the effects of preoperative simvastatin treatment on systemic inflammatory response and perioperative morbidity after cardiopulmonary bypass. METHODS: A prospective, randomized study, was designed. Forty-four subjects undergoing elective coronary artery bypass grafting who fulfilled the inclusion criteria were randomized to treatment with simvastatin (20 mg/day, group A, N. 22) or control (group B, N. 22) before surgery. Plasma levels of interleukins (IL-6, IL-8, TNF-alpha), and systemic inflammatory response score (SIRS) were measured during the surgical intervention and over the following 48 postoperative hours. Cytokine levels were measured by enzyme-linked assays from plasma samples obtained at specific time points pre- and post-operation. RESULTS: In both groups the serum levels of the proinflammatory cytokines (IL-6, IL-8, TNF-alpha), and leukocytes, and the SIRS score increased significantly over the baseline, though no significant differences were observed between the two groups. The preoperative and postoperative course did not differ between both groups. CONCLUSIONS: In patients undergoing coronary artery bypass grafting with cardiopulmonary bypass, the administration of simvastatin doses not produce any changes in the inflammatory response as measured by the levels of IL-6, IL-8, TNF-alpha and SIRS score, nor does it reduce the complications after cardiac surgery.

The inflammatory response to colloids and crystalloids used for pump priming during cardiopulmonary bypass.

BACKGROUND: Systemic inflammatory response frequently occurs after coronary artery bypass surgery and is strongly correlated with the risk of postoperative morbidity and mortality. This study tests the hypothesis that the priming of the extracorporeal circuit with colloid solutions results in less inflammation in patients undergoing cardiac surgery than priming with crystalloid solutions. METHODS: A prospective, randomized study was designed. Forty-four patients undergoing elective coronary artery bypass grafting were randomly allocated to one of two groups: 22 patients primed with Ringer's lactate (RL) solution and 22 patients primed with gelatin-containing solution during the surgery. Plasma levels of interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP) and, complement 4 were measured during the surgical intervention and over the following 48 postoperative hours. Cytokine levels were measured by enzyme-linked assays from plasma samples obtained at specific time points pre- and post-operatively. RESULTS: In both groups the serum levels of the pro-inflammatory cytokines (IL-6, IL-8, TNF-alpha), CRP, complement 4, and leukocytes increased significantly over the baseline, although no significant differences were observed between the two groups. The operation time, blood loss, need for inotropic support, extubation time, and length of intensive care unit stay did not differ significantly between the two groups. CONCLUSION: Priming with gelatin vs. RL produces no significant differences in the inflammatory response in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

[Central venous pressure, rewarming time, and total fluid replacement volume are predictors of mortality and complications after cardiac surgery]. / Presión venosa central, tiempo de recalentamiento y líquidos totales son factores postoperatorios de morbi-mortalidad en cirugía cardiaca.

OBJECTIVE: To analyze the influence of early (first day) postoperative factors on postoperative course in patients who have undergone heart surgery. PATIENTS AND METHODS: A cross-sectional study of consecutively enrolled heart surgery patients was designed. We recorded central venous pressure, time required for rewarming to a core temperature of 35.5degrees C, and total fluids administered in 24 hours. We then analyzed their influence on mortality and cardiac, pulmonary, and renal complications. RESULTS: Two hundred thirty-six patients were included. Central venous pressure over 18 mm Hg, time to rewarming over 6 hours, and administration of more than 5 L of fluids in the first 24 hours were factors associated with increased mortality and the development of cardiovascular, pulmonary, and renal complications. CONCLUSIONS: Central venous pressure, rewarming time, and fluid replacement volume required on the first day are predictors of postoperative course.

[Postoperative analgesia in cardiac surgery: spinal versus intravenous morphine]. / Analgesia postoperatoria en cirugía cardiaca: comparación de morfina intratecal versus morfina intravenosa.

OBJECTIVE: To compare the effects of spinal and intravenous administration of morphine to supplement anesthesia with remifentanil in terms of analgesia during early postoperative recovery and considering time until extubation. MATERIAL AND METHODS: This prospective, randomized, blinded trial enrolled 59 patients scheduled for cardiac surgery. The patients were assigned to receive either a spinal infusion of morphine (15 microg x Kg(-1)) or an intravenous infusion (0.3 mg x Kg(-1)). Anesthesia was maintained with 0.15 to 0.50 microg x Kg(-1) x min(-1) of remifentanil and 2 to 4 mg x Kg(-1) x h(-1) of propofol in perfusion. After the period of extracorporeal circulation, all patients were given an intravenous infusion of 30 mg of ketorolac. Later intravenous ketorolac was ministered at a dose of 30 mg per 8 hours; intravenous morphine (bolus dose of 3 mg) was also administered until pain was relieved. RESULTS: The same quality of postoperative analgesia and anesthetic recovery was achieved with both spinal and intravenous administration. The incidence of side effects was also similar. Likewise, the extubation times were similar in the 2 groups (spinal infusion group: 294.5 [SD, 150.5] minutes; intravenous group: 325.0 [139.9] minutes; P>0.05). Less postoperative intravenous morphine was administered in the first 24 hours to patients in the spinal morphine group (P<0.05) and fewer patients in that group required intravenous morphine boluses (P<0.05). CONCLUSIONS: Our study suggests that spinal morphine does not offer advantages over intravenous morphine with regard to postoperative analgesia, hemodynamic stability and respiratory parameters, time until extubation, or adverse effects.

[Evaluation of the withdrawal of ACE inhibitors in coronary artery surgery]. / Valutazione della sospensione degli ACE-inibitori in chirurgia cardiaca coronarica.

During cardiac surgery, as a result of surgical aggression, myocardial ischaemia and cardiopulmonary bypass, the renin-angiotensin-aldosterone mechanism is intensely activated. Our aim is to document whether, in the case of patients undergoing chronic treatment with lisinopril, the non-withdrawal of this inhibitor's administration before cardiac surgery and the administering of a last dose on the day of the operation are associated with coronary haemodynamic alterations. A study was made of 18 patients submitted to myocardial revascularization under extracorporeal circulation and distributed in two groups: group A) without ACE inhibitorsplacebo, group B) with ACE inhibitors (Lisinopril). Coronary blood flow (CBF) was determined by inverted thermodilution via Baim's catheter. Coronary and metabolic haemodynamic values were calculated. Lisinopril had no significant influence on the CBF or on the other above-mentioned values. Therefore, it is not necessary to withdraw ACE inhibitors in cardiac surgery interventions.

[Right heart support during coronary artery bypass grafting without cardiopulmonary bypass]. / Asistencia ventricular derecha en cirugía coronaria sin derivación cardiopulmonar.

BACKGROUND AND OBJECTIVES: Exposure of lateral and inferior coronary vessels during off-pump coronary artery bypass grafting may cause significant hemodynamic compromise due to right ventricular compression when tilting the heart. Some new right ventricular assistance devices have been developed in order to avoid this problem but only a few series have been published. A preliminary experience with a right heart circulatory support system is reported. METHODS: A total of eight patients underwent off-pump coronary artery bypass grafting using a right heart support device. Technical procedure and clinical outcome are analyzed. RESULTS: The right heart circulatory support device insertion and management were performed without any complication. A total of 21 distal coronary anastomoses were completed. They were located on the anterior descending artery(8), circumflex branches(6), diagonal branches(2), posterior descending artery(3) and right coronary artery(2). The right ventricular support device delivered flow at a medium rate of 2.2 L/min, providing hemodynamic stability when tilting the heart and exposing the coronary arteries. CONCLUSIONS: The use of right heart support devices is a simple and low risk procedure which may facilitate surgical anastomoses on lateral and inferior epicardial vessels during off-pump coronary artery surgery.

Apoptotic cell death and genetic control in graft coronary artery disease in heart transplant.

AIM: Apoptosis is a type of programmed cell death whereby, immunologic, genetic and biochemical mechanisms are involved in its control. On the other hand, graft coronary artery disease is the most important restrictive factor for the long-term survival of heart transplantation. The purpose of this study is to analyse both apoptotic cell lesions in transplanted patients that present coronary artery disease. METHODS: From August 1984 until December 1996, 148 heart transplants were carried out in the Clínica Universitaria de Navarra. In 102 patients, annual coronary angiography was performed, reaching a diagnosis of coronary artery disease in 30 patients. Study of apoptotic cell death was done in the tissue of endomyocardial biopsies on all patients by means of the TUNEL technique. Procedures of immunohistochemistry with antibodies antic-myc, p53 and bcl-2 were carried out and results were compared with a control group of 30 patients with homogeneous characteristics. RESULTS: All patients with coronary artery disease showed apoptotic cardiomyocytes, 13 patients to a mild degree, 14 to a moderate degree and 3 to a severe degree, while in the control group apoptosis was found only to a mild degree in 8 patients, obtaining a very significant statistical difference (p<0.0001). The expression of analysed oncoproteins was null in the 2 groups. CONCLUSION: Myocardial apoptosis is a constant finding in transplanted patients with coronary artery disease. We have not seen any correlation between the apoptotic process and genetic mechanisms.

Bilateral diaphragmatic paralysis after open heart surgery.

The purpose of the present case report is to present a case of bilateral diaphragmatic paralysis as a complication of open-heart surgery. A 47-year-old male was operated for aortic and mitral valve replacement. After discontinuation of sedation, bilateral diaphragmatic paralysis as well as motor and sensitive dysfunction in the four extremities was observed. The patient remained with mechanical ventilation support for twenty months. Two years after the operation a complete normalisation of the diaphragmatic motion was observed. Although uncommon, bilateral diaphragmatic paralysis after open-heart surgery could take place, being necessary long term mechanical ventilation support until recovery.

Analysis of the microenvironment necessary for engraftment: role of the vascular smooth muscle-like stromal cells.

This is a review of recent data concerning the phenotype of human and murine stroma, as grown in long-term cultures. Using data on cytoskeletal and extracellular matrix protein expression, a sequential model of differentiation from mesenchymal (stem) cells to vascular-smooth muscle-like stromal cells is proposed. This model would apply, at least in the mouse, to stromal cells generated from different sites of hematopoiesis (bone marrow, fetal liver, spleen, and yolk sac). The in vivo counterparts of vascular-smooth muscle-like stromal cells in the different sites of definitive hematopoiesis are discussed.

Entamoeba histolytica: a eukaryote with trypanothione metabolism instead of glutathione metabolism.

Entamoeba histolytica is a human pathogen that lacks the capacity to synthesize glutathione but can incorporate it, from the growth media or presumably from the human host, to form trypanothione [N(1), N(8)-bis(glutathionyl)-spermidine conjugate]. This novel thiol compound has previously been found in trypanosomatids, as has its precursor glutathionyl-spermidine, which was originally detected in Escherichia coli. Previously we showed the presence of these two thiol compounds in extracts from cultures of Entamoeba histolytica HK9. Here we report that when Entamoeba histolytica HK9 is grown in a culture medium that lacks glutathione (treated with the enzyme gamma-glutamyl transpeptidase), trypanothione is not formed, although the trophozoites can continue dividing for at least 60 h but at 25% lower cell density. The finding of a trypanothione metabolism in Entamoeba histolytica raises many questions: one concerns the possibility of a phylogenetic relationship, in this respect, with trypanosomatids such as Trypanosoma cruzi, T. brucei and Crithidia fasciculata; another concerns its role in cell metabolism; a third concerns it possible use as a target for a rational drug design strategy against this parasite.

Spectral and thermal properties of ondansetron

Realizou-se estudo das propriedades gerais da ondansetrona. A estabilidade térmica do sólido é ensaiada mediante determinação do comportamento termogravimétrico e do ponto de fusão. A descrição das características e a interpretação do comportamento térmico são complementadas por meio de estudos espectrométricos: IV, RMH-Hû, RMN-ûüC, UV-VIS e fluorescência

[The effect of isoflurane on coronary autoregulation in hypothermia]. / Efecto del isoflurano sobre la autorregulación coronaria en hipotermia.

OBJECTIVES: To analyze the effect of isoflurane on myocardial metabolism and coronary hemodynamics during the reheating phase after heart surgery. PATIENTS AND METHODS: Sixteen patients (12 women and 4 men), with cardiac output greater than 0.5 undergoing aortic and/or mitral valve surgery, were studied prospectively. A retrograde thermodilution catheter was placed in the heart and a Swan-Ganz catheter was inserted in the pulmonary artery to determine coronary blood flow and pulmonary wedge pressure, respectively, as well as myocardial and systemic parameters. After surgery, and with hemodynamic variables stable and rectal temperature at 34 +/- 0.5 degrees C, 0.4% isoflurane was administered at the end of expiration. Variables were recorded before administering isoflurane and 20 minutes afterwards. RESULTS: Isoflurane administration decreased coronary perfusion pressure, coronary vascular resistance, regional myocardial oxygen consumption and myocardial oxygen output. Increases in coronary oxygen saturation and in large coronary vein saturation were also observed. No patient experienced significant changes in ST segment, enzymes or decreased clearance of lactic acid. CONCLUSIONS: Administering 0.4% isoflurane at the end of expiration effected coronary vasodilation without altering oxygenation or myocardial metabolism. Moreover, no electrocardiographic, enzymatic or metabolic signs of myocardial ischemia were observed.

[Congenital cysts of the nasopharynx. Report of a case]. / Quistes congénitos de nasofaringe. Presentación de un caso.

Congenital nasopharyngeal cysts are uncommon and usually located on the lateral wall of the nasopharynx. The literature groups lateral and medial cysts although they have different origins. A congenital nasopharyngead cyst in a 67-year-old man was diagnosed and treated. His only symptom was right hearing loss caused by secretory otitis. After cyst excision using a transpalatine approach, his hearing loss resolved within 4 days. Nasopharyngeal cyst types and their histological and anatomic differentiation are discussed. Therapeutic options and approaches are considered, and the need for total exeresis of the cyst with its capsule is noted.