Eculizumab Modifies Outcomes in Adults with Atypical Hemolytic Uremic Syndrome with Acute Kidney Injury.

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a rare disease associated with congenital or acquired genetic abnormalities that result in uncontrolled complement activation, leading to thrombotic microangiopathy and kidney failure. Until recently, the only treatment was plasma exchange or plasma infusion (PE/PI), but 60% of patients died or had permanent kidney damage despite treatment. Eculizumab, a complement inhibitor, has shown promising results in aHUS. However, data are mainly extracted from case reports or studies of heterogeneous cohorts, and no direct comparison with PE/PI is available. METHODS: An observational retrospective study of adult, dialysis-dependent aHUS patients with acute kidney injury (AKI) who were treated with either PE/PI alone or with second-line eculizumab in our center. We compared the effect of PE/PI and eculizumab on kidney function, hypertension, proteinuria, hematologic values, relapse, and death. RESULTS: Thirty-one patients were included (females, 18; sporadic aHUS, 29; mean age, 46 ± 20 years). Twenty-six patients were treated with PE/PI alone, and 5 were deemed to be plasma-resistant and received eculizumab after stopping PE/PI. Among patients receiving eculizumab, 80% attained complete recovery of kidney function, 100% stopped dialysis, 20% had decreased proteinuria, and no patient relapsed (vs. 38.5, 50, 15.4, and 11.5%, respectively, of patients receiving only PE/PI). At 1-year of follow-up, no deaths had occurred in either group. CONCLUSION: Eculizumab shows greater efficacy than PE/PI alone for the treatment of adult aHUS patients with AKI. Prospective studies and meta-analyses are warranted to confirm our findings and set guidelines for treatment, monitoring, and maintenance.

Identification of predictive factors of the degree of adherence to the Mediterranean diet through machine-learning techniques.

Food consumption patterns have undergone changes that in recent years have resulted in serious health problems. Studies based on the evaluation of the nutritional status have determined that the adoption of a food pattern-based primarily on a Mediterranean diet (MD) has a preventive role, as well as the ability to mitigate the negative effects of certain pathologies. A group of more than 500 adults aged over 40 years from our cohort in Northwestern Spain was surveyed. Under our experimental design, 10 experiments were run with four different machine-learning algorithms and the predictive factors most relevant to the adherence of a MD were identified. A feature selection approach was explored and under a null hypothesis test, it was concluded that only 16 measures were of relevance, suggesting the strength of this observational study. Our findings indicate that the following factors have the highest predictive value in terms of the degree of adherence to the MD: basal metabolic rate, mini nutritional assessment questionnaire total score, weight, height, bone density, waist-hip ratio, smoking habits, age, EDI-OD, circumference of the arm, activity metabolism, subscapular skinfold, subscapular circumference in cm, circumference of the waist, circumference of the calf and brachial area.

Spitzoid melanoma in children: clinicopathological study and application of immunohistochemistry as an adjunct diagnostic tool.

INTRODUCTION: The term spitzoid melanoma (SM) is reserved for a rare group of tumors with striking resemblance to Spitz nevus, often developing in children diagnosed in retrospect after the development of metastases. OBJECTIVES: To determine the biological significance of SM and to analyze the effectiveness of adjuvant diagnostic techniques. MATERIALS AND METHODS: A retrospective, observational study of 38 cases of SM in patients younger than 18 years. Histological type, Clark level and Breslow thickness, radial and vertical growth phase, mitotic count/mm(2), ulceration, regression, vascular and perineural invasion, satellitosis, cytology and associated nevi were reviewed. An immunohistochemical analysis with HMB45 and Ki67 was performed in 10 cases. These features were correlated to patient's stage and outcome. RESULTS: Analysis of histological and immunohistochemical features should allow accurate diagnosis in most cases. Given the low mortality rate, no conclusions about the prognostic significance of histological parameters of the primary tumor could be established. CONCLUSION: We report the largest series of SM from a unique center. Although these patients may have a better prognosis than adults, some patients with SM develop metastasis and die, particularly after age 11 years. Therefore, we recommend using the same treatments as in adults.

Factors influencing delay in the diagnosis of colorectal cancer: a study protocol.

BACKGROUND: Colorectal cancer (CRC) is the second most frequent tumor in developed countries. Since survival from CRC depends mostly on disease stage at the time of diagnosis, individuals with symptoms or signs suspicious of CRC should be examined without delay. Many factors, however, intervene between symptom onset and diagnosis. This study was designed to: 1) Describe the diagnostic process of CRC from the onset of first symptoms to diagnosis and treatment. 2) Establish the time interval from initial symptoms to diagnosis and treatment, globally and considering patient's and doctors' delay, with the latter due to family physician and/or hospital services. 3) Identify the factors related to defined types of delay. 4) Assess the concordance between information included in primary health care and hospital clinical records regarding onset of first symptoms. METHODS: Descriptive study, coordinated, with 5 participant groups of 5 different Spanish regions (Balearic Islands, Galicia, Catalunya, Aragon and Valencia Health Districts), with a total of 8 acute public hospitals and 140 primary care centers. Incident cases of CRC during the study period, as identified from pathology services at the involved hospitals. A sample size of 896 subjects has been estimated, 150 subjects for each participant group. Information will be collected through patient interviews and primary health care and hospital clinical records. Patient variables will include sociodemographic variables, family history of cancer, symptom perception, and confidence in the family physician; tumor variables will include tumor site, histological type, grade and stage; symptom variables will include date of onset, type and number of symptoms; health system variables will include number of patient contacts with family physician, type and content of the referral, hospital services attending the patient, diagnostic modalities and results; and delay intervals, including global delays and delays attributed to the patient, family physician and hospital. DISCUSSION: To obtain a nonrestricted sample of patients with CRC we have minimized selection risk by identifying the patients from pathology services. A greater constraint may be associated with information sources based on clinical records. Due to inherent features of coordinated studies, it is important to standardize the collection of information.

Comparative Study of Survival following Videothoracoscopic Lobectomy Procedures for Lung Cancer: Single- versus Multiple-port Approaches. / Estudio comparativo de la supervivencia tras procedimientos videotoracoscópicos para la lobectomía del cáncer de pulmón: abordaje por puerto único frente a múltiple.

INTRODUCTION: Video-assisted thoracoscopic surgery has become the technique of choice in the early stages of lung cancer in many centers although there is no evidence that all of the surgical approaches achieve the same long-term survival. METHOD: We carried out a retrospective review of 276 VATS lobectomies performed in our department, analyzing age, sex, comorbidities, current smoker, FEV1 and FCV, surgical approach, TNM and pathological stage, histologic type, neoadjuvant or coadjuvant chemotherapy, relapse and metastasis time, with the main aim of evaluating the survival rate and disease-free time, especially with regard to the two/three versus single port approach. RESULT: The one/four year global survival rate was 88.1 and 67.6% respectively. Bivariate analysis found that the variables associated with survival are comorbidity, histological type, stage, surgical approach and need for chemotherapy. When we independently analyzed the surgical approach, we found a lower survival rate in the single-port group vs. the two/three-port group (VATS). Stratifying by tumoral stage (stage I) and by tumor size (T2) survival was significantly lower for patients with single-port group in comparison to VATS approach. In the multivariate analysis, single-port group is associated with a higher risk of death (HR=1.78). In analyzing disease-free survival, differences were found in both cases in favor of two/three port VATS: p=.093 for local relapses and p=.091 for the development of metastasis. CONCLUSIONS: These results challenge the use of the single port technique in malignant lung pathologies, suggesting the need for clinical trials in order to identify the role this technique may have in lung cancer surgery.

Single-lung transplantation in emphysema: Retrospective study analyzing survival and waiting list mortality.

AIM: To performed remains a subject of debate and is the principal aim of the study. METHODS: This retrospective analysis included 73 patients with emphysema (2000-2012). The outcomes of patients undergoing single-lung transplantation (SL) (n = 40) or double-lung transplant (DL) (n = 33) were compared in a Cox multivariate analysis to study the impact of the technique, postoperative complications and acute and chronic rejection on survival rates. Patients were selected for inclusion in the waiting list according to the International Society of Heart Lung Transplantation criteria. Pre and postoperative rehabilitation and prophylaxis, surgical technique and immunosuppressive treatment were similar in every patients. Lung transplantation waiting list information on a national level and retrospective data on emphysema patient survival transplanted in Spain during the study period, was obtained from the lung transplantation registry managed by the National Transplant Organization (ONT). RESULTS: Both groups were comparable in terms of gender and clinical characteristics. We found significant differences in the mean age between the groups, the DL patients being younger as expected from the inclusion criteria. Perioperative complications occurred in 27.6% SL vs 54% DL (P = 0.032). Excluding perioperative mortality, median survival was 65.3 mo for SL and 59.4 mo for DL (P = 0.96). Bronchiolitis obliterans and overall 5-year survival were similar in both groups. Bacterial respiratory infection, cytomegalovirus and fungal infection rates were higher but not significant in SL. No differences were found between type of transplant and survival (P = 0.48). To support our results, national data on all patients with emphysema in waiting list were obtained (n = 1001). Mortality on the waiting list was 2.4% for SL vs 6.2% for DL. There was no difference in 5 year survival between 235 SL and 430 DL patients transplanted (P = 0.875). CONCLUSION: Our results suggest that SL transplantation in emphysema produce similar survival than DL with less postoperative complication and significant lower mortality in waiting list.

[Preoperative risk evaluation in beating-heart coronary artery bypass surgery]. / Evaluación preoperatoria del riesgo en la cirugía coronaria sin circulación extracorpórea.

INTRODUCTION AND OBJECTIVES: Operative risk stratification scales for use in cardiac surgery have been developed for patients who undergo procedures using extracorporeal circulation. The aims of the present study were to investigate the use of six preoperative risk stratification scales in patients undergoing beating-heart surgery and to identify risk factors for major complications and mortality in our group of patients who underwent revascularization using this approach. PATIENTS AND METHOD: Between January 1997 and December 2002, we performed 762 coronary artery bypass operations on the beating heart; 61 patients suffered major complications (8%) and 25 died (3.3%). Risk factors for major complications and death were identified using logistic regression analysis of prospectively collected data. The following risk scores were calculated for each patient: Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario, and French. Receiver operating characteristic curves were used to compare the ability of each scale to predict mortality and major complications. RESULTS: In our patient group, the preoperative variables associated with increased risk were: need for cardiopulmonary resuscitation, renal dysfunction, peripheral vasculopathy, and the presence of severe left main coronary artery disease, three-vessel disease, or an impaired ejection fraction. CONCLUSIONS: Mortality and major complications were best predicted by the Parsonnet 95 and Euroscore scales.

Estudio comparativo de la supervivencia tras procedimientos videotoracoscópicos para la lobectomía del cáncer de pulmón: abordaje por puerto único frente a múltiple / Comparative study of survival following videothoracoscopic lobectomy procedures for lung cancer: single-versus multiple-port approaches

Introducción: La cirugía toracoscópica videoasistida se ha convertido en la técnica de elección para las intervenciones de cáncer de pulmón en estadio inicial en muchos centros, a pesar de que no se ha probado que la supervivencia a largo plazo sea la misma con todos los abordajes quirúrgicos. Método: Efectuamos una revisión retrospectiva de 276 lobectomías practicadas en nuestro servicio mediante cirugía videoasistida, y analizamos la edad, sexo, comorbilidades, tabaquismo, FEV1 y FCV, abordaje quirúrgico, estadios TNM y patológico, tipo histológico, quimioterapia neoadyuvante o coadyuvante y tiempo hasta la recidiva o la detección de metástasis con el objetivo de evaluar la tasa de supervivencia y la duración del periodo sin enfermedad en relación con el abordaje quirúrgico, dos/tres puertos o puerto único, de los pacientes. Resultados: Las tasas de supervivencia global al cabo de uno y cuatro años fueron del 88,1 y 67,6%, respectivamente. En el análisis bivariante se observó que las variables que se asociaban con la supervivencia eran las comorbilidades, el tipo histológico, el estadio, el abordaje quirúrgico y la necesidad de quimioterapia. Al analizar el abordaje quirúrgico de forma independiente, se observó que la tasa de supervivencia era inferior en el grupo en el que se utilizó la técnica monoportal frente al grupo en el que se utilizaron dos o tres puertos (VATS). Al estratificar a los pacientes según el estadio tumoral (estadio I) y el tamaño del tumor (T2), la supervivencia fue significativamente inferior en los pacientes tratados con el abordaje monoportal, en comparación con la VATS. En el análisis multivariante, el riesgo de muerte fue mayor con la técnica monoportal (HR = 1,78). En el análisis del tiempo transcurrido sin enfermedad se observó una tendencia hacia una mayor supervivencia favorable a la VATS con dos/tres puertos, tanto para la recidiva local (p = 0,093) como para el desarrollo de metástasis (p = 0,091). Conclusiones: Estos resultados cuestionan el uso de la técnica uniportal en las neoplasias malignas de pulmón, lo que sugiere la necesidad de efectuar ensayos clínicos que permitan identificar el papel de esta técnica en la cirugía del cáncer de pulmón

Introduction: Video-assisted thoracoscopic surgery has become the technique of choice in the early stages of lung cancer in many centers although there is no evidence that all of the surgical approaches achieve the same long-term survival. Method: We carried out a retrospective review of 276 VATS lobectomies performed in our department, analyzing age, sex, comorbidities, current smoker, FEV1 and FCV, surgical approach, TNM and pathological stage, histologic type, neoadjuvant or coadjuvant chemotherapy, relapse and metastasis time, with the main aim of evaluating the survival rate and disease-free time, especially with regard to the two/three versus single port approach. Result: The one/four year global survival rate was 88.1 and 67.6% respectively. Bivariate analysis found that the variables associated with survival are comorbidity, histological type, stage, surgical approach and need for chemotherapy. When we independently analyzed the surgical approach, we found a lower survival rate in the single-port group vs. the two/three-port group (VATS). Stratifying by tumoral stage (stage I) and by tumor size (T2) survival was significantly lower for patients with single-port group in comparison to VATS approach. In the multivariate analysis, single-port group is associated with a higher risk of death (HR = 1.78). In analyzing disease-free survival, differences were found in both cases in favor of two/three port VATS: p = .093 for local relapses and p = .091 for the development of metastasis. Conclusions: These results challenge the use of the single port technique in malignant lung pathologies, suggesting the need for clinical trials in order to identify the role this technique may have in lung cancer surgery

The use of ertapenem for the treatment of community-acquired pneumonia in routine hospital practice: a matched cohort study / Uso de ertapenem en la neumonía adquirida en la comunidad en la práctica clínica diaria: estudio de cohortes pareadas

Background. The clinical response to ertapenem in community-acquired pneumonia (CAP) at the setting of routine hospital practice has been scarcely evaluated. Methods. We retrospectively compared CAP cases treated with ertapenem or with other standard antimicrobials (controls) at a tertiary 1,434-bed center from 2005 to 2014. Results. Out of 6,145 patients hospitalized with CAP, 64 (1%) ertapenem-treated and 128 controls were studied (PSI IV-V 72%, mean age 73 years.). A significant higher proportion of bedridden patients (41% vs. 21%), residence in nursing homes (19% vs. 7%), previous use of antibiotics (39% vs. 29%) and necrotizing (13% vs. 1%) or complicated (36% vs. 19%) pneumonia, was observed in the ertapenem vs. non-ertapenem patients. Initial treatment with ertapenem was independently associated with an earlier resolution of signs of infection. In patients aged 65 or older the independent risks factors for mortality were: PSI score (7.0, 95%CI 1.8-27.7), bedridden status (4.6, 95%CI 1.1-20.9) and Health Care Associated Pneumonia (HCAP) (4.6, 95%CI 1.3-16.5). First-line treatment with ertapenem was an independent protector factor in this subgroup of patients (0.1, 95%CI 0.1-0.7). Conclusions. Ertapenem showed a superior clinical response in frail elderly patients with complicated community- acquired pneumonia, and it may be considered as a firstline therapeutic regimen in this setting (AU)

Introducción. La respuesta clínica a ertapenem en la neumonía adquirida en la comunidad (NAC) en el contexto de la práctica clínica diaria ha sido evaluada de forma insuficiente. Material y Métodos. Estudio retrospectivo, comparativo de pacientes con NAC tratados con ertapenem o con otros antimicrobianos en un hospital terciario de 1.434 camas en el período 2005-2014. Resultados. De los 6.145 pacientes hospitalizados con NAC, 64 (1%) tratados con ertapenem y 128 controles fueron incluidos en el estudio (PSI IV-V 72%, edad media 73 años). Se observó una proporción significativamente mayor de pacientes encamados (41% vs. 21%), institucionalizados (19% vs. 7%), con antibioterapia previa (39% vs. 29%) y con neumonías necrotizantes (13% vs. 1%) o complicadas (36% vs. 19%) en el grupo de ertapenem vs. no-ertapenem. El tratamiento inicial con ertapenem se asoció de forma independiente con una resolución más temprana de los signos de infección. En el subgrupo de pacientes con 65 años o más, los factores independientes de riesgo de mortalidad fueron: PSI score (7,0 IC95% 1,8-27,7), encamamiento (4,6 IC95% 1,1-20,9) y la Neumonía Asociada a Cuidados Sanitarios (NACS) (4,6 IC95% 1,3-16,5). El tratamiento en primera línea con ertapenem fue un factor protector independiente en este grupo de pacientes (0,1 IC95% 0,1-0,7). Conclusiones. El tratamiento con ertapenem se asoció a una respuesta clínica superior en el paciente anciano frágil con NAC complicada y se podría considerar como un régimen terapéutico de primera línea en este contexto (AU)

A model for predicting mortality among critically ill burn victims.

OBJECTIVE: To develop a model for predicting mortality among burn victims. METHODS: All casualties admitted to our intensive care burn unit (ICBU) with a diagnosis of thermal or inhalation injury were studied. Age, total and full-thickness body surface area (BSA) burned, presence of inhalation injury, gender, mechanism of injury, delay to ICBU admission and mechanical ventilation during the first 72 h were recorded. The 851 participants were randomly divided into derivation (671) and validation (180) sets. From univariate and multivariate logistic regression analyses a mortality predictive equation was derived. RESULTS: Mortality was 17.6%. In univariate analysis, all variables were significantly associated with mortality except mechanism of injury and delay to ICBU admission. In multivariate analysis, age, total and full-thickness BSA burned, female gender and early mechanical ventilation were independently associated with mortality. CONCLUSIONS: We propose a mortality predictive equation for burned victims. In this model, MV and not inhalation injury is a mortality risk factor.

Peak expiratory flow rate as predictor of inpatient death in patients with chronic obstructive pulmonary disease.

OBJECTIVES: Few studies analyze hospital deaths and related factors in patients with acute exacerbation of chronic obstructive pulmonary disease who require hospitalization. METHODS: A cross-sectional study was done with 284 patients who had been admitted consecutively to the Short Stay Medical Unit at the Juan Canalejo Hospital in A Coruña. RESULTS: Eleven patients (3.9%) died. The independent variables for predicting death were the peak expiratory flow (OR, 0.96; 95% CI, 0.94 to 0.98), long-term oxygen therapy (OR, 12.46; 95% CI, 2.1 to 72.4), and body mass index (OR, 0.73; 95% CI, 0.59 to 0.90). A peak expiratory flow < 150 L/min showed the best specificity and positive predictive value with maximum sensitivity for predicting death. The results of the arterial blood gasses and the functional tests did not predict hospital death. CONCLUSIONS: Peak expiratory flow was the most important predictive value for determining the risk of death in patients who required hospitalization for acute exacerbation of chronic obstructive pulmonary disease. Additional studies are required to validate these findings.

[Incidence, risk factors and influence on survival of infectious complications in liver transplantation]. / Incidencia, factores de riesgo e influencia sobre la supervivencia de las complicaciones infecciosas en el trasplante hepático.

INTRODUCTION: Orthotopic liver transplantation (OLT) is successful therapy for patients with end-stage liver disease. Infection is currently a life-threatening complication for these patients. The aims of this study are to determine the incidence of various infections in patients with OLT, to study overall survival rates and survival as related to individual infections, and to investigate the risk factors associated with first episodes of bacterial (BI), fungal (FI), invasive fungal (IFI) and cytomegalovirus (CMV) infections. METHODS: The study includes 165 OLTs performed in 152 recipients from May 1994 to May 1998. A descriptive analysis estimating the 95% confidence interval was performed with 100 variables stratified according to preoperative, operative and postoperative conditions. Cox regression analysis was used to identify the variables associated with infection. Survival studies were carried out with the Kaplan-Meier method. RESULTS: Among the total, 66% of patients developed infection: 41.8% viral, 33.9% BI, 20.6% FI and 4.2% IFI. One-year and 4-year survival rates after transplantation were 90% and 75%, respectively. All the infections decreased survival. Multivariate analyses identified the following risk factors for the specific infections: BI - dialysis, mechanical ventilation, and time of organ ischemia during harvesting; FI - number of hours of surgery and pretransplantation plasma albumin concentrations; IFI - number of blood units transfused, pretransplantation plasma albumin and retransplantation. Cytomegalovirus infection was associated with FI and IFI in the univariate analysis, but the multivariate analysis identified no variables that independently increased the risk of developing this infection.

Presentation and prognosis of gastric cancer in patients aged 80 years and older.

The aim of this study was to analyze the characteristics of the presentation and prognosis of patients aged >/= 80 who were diagnosed with gastric adenocarcinoma. We have used a retrospective cohort study of 2334 patients diagnosed between 1975 and 1993 in northwestern Spain, 263 (11.3%)of whom were >/= 80 years of age. No differences were observed with respect to patients of a younger age at diagnosis regarding the site of the tumor, extension of the disease, or Laurén's histologic type. However, fewer resections with curative intent were performed in the older group (49.1% vs. 30.1%; p < 0.0001). Among those operated on with curative or palliative intent, at the end of the first month the survival probability was 0.9 and the 0.95% confidence interval (CI 95%) was 0.93-0.97 for patients < 80 years of age and 0.93 (CI 95% 0.89-0.98) for the older group ( p = 0.19). At the end of 5 years of follow-up these probabilities were 0.29 (CI 95% 0.27-0.31) and 0.18 (CI 95% 0.14-0.23), respectively ( p < 0.0001). If we consider only those patients undergoing curative resection, the survival probability for the two groups ( p = 0.4) was not statistically different. In conclusion, although the two groups showed similar characteristics at presentation, patients >/= 80 years of age underwent surgery with curative intent less frequently and their general prognosis was worse. Our data support the idea that curative surgery should not be ruled out exclusively for reasons of age.

Factores preoperatorios predictores de morbimortalidad. Mayor en la cirugía coronaria sin el uso de la circulación extracorpórea. Presentación del Canalejo Score / No disponible

Objetivos: Este es un estudio cooperativo entre el “Hospital Juan Canalejo” in A Coruña, Galicia España y el Cardiocentro “Ernesto Ché Guevara” de Villa Clara, Cuba. Este trabajo fue realizado con el objetivo de conocer cuáles son los factores de riesgo predictores de morbimortalidad mayor en los pacientes revascularizados sin el uso de la circulación extracorpórea (OPCABG) y mostrar un informe sobre la construcción del Canalejo Score. Método: De enero de 1997 a diciembre del 2002, un total de 762 pacientes fueron sometidos a cirugía de revascularización miocárdica sin el uso de la circulación extracorpórea en el servicio de cirugía cardiaca del Complejo hospitalario Juan Canalejo de A Coruña, Galicia, España. Fallecieron 25 pacientes lo que representa un 3,3% de total y presentaron complicaciones mayores 61 pacientes (8% del total de pacientes). Las variables estudiadas en cada paciente fueron recogidas de forma estudiadas en cada paciente fueron recogidas de forma prospectiva en la base de datos Apolo del servicio de cirugía cardiaca de nuestro Hospital. Para determinar las variables predictoras de presencia de eventos de interés se realizó un análisis de regresión logística utilizando como variable dependiente las complicaciones mayores y como covariables las variables que en el análisis univariado estuviesen asociadas a dichas variables o fuesen clínicamente o quirúrgicamente relevantes. Con dichas variables y teniendo en cuenta el coeficiente de regresión se calculó el score. (Canalejo score). La precisión y el poder discriminante del modelo fueron evaluados con curvas ROC. El Canalejo score fue validado en un total de 200 pacientes, de ellos 16 son fallecidos y 22 son complicaciones mayores que fueron sometidos a OPCABG durante el año 2004 en el Cardiocentro “Ernesto Ché Guevara” de Villa Clara, Cuba. Resultados y conclusiones. Las variables que modifican significativamente el riesgo de tener complicaciones mayores son: la insuficiencia renal, la arteriopatía periférica, la resucitación cardiopulmonar, la enfermedad del tronco de la arteria coronaria izquierda más los tres vasos coronarios con lesiones significativas, el antecedente de accidente cerebrovascular con secuelas, la inestabilidad hemodinámica y la fracción de eyección. El área bajo la curva con la probabilidad del modelo para predecir complicaciones mayores fue del 80% (AU)

Objective: This a cooperative study between “Juan Canalejo Hospital” in A Coruña, Galicia, Spain and “Ernesto Ché Guevara” heart Institute in Cuba. The aim of this study is to know the risk factors to predict greater morbidity in patients that underwent coronary artery bypass grafting surgery without extracorporeal circulation (OPCABG) and show the preliminary report about how we built the Canalejo score. Methods: Between January 1, 1997 and December 30, 2002, 762 patients underwent OPCABG in the cardiac service of Juan Canalejo Hospital in A Coruña, Galicia, Spain, Twenty five patients (3,3%) died in the first month postoperative and Sixty one patients (8%) had greater morbidity. The variables that were investigated in each patient were collected in prospect form in the Apolo database. To know the preoperative risk factors to predict greater morbidity a multivariate logistic regression analysis were developed. The Canalejo score was built with the variables to reach statistic significant in the logistic regression analysis. The Canalejo score was built with the variables to reach statistic significant in the logistic regression analysis. The weight of each variable into de score was calculated according the coefficient? In the logistic regression analysis. The weight of each variable into the score was calculated according the coefficient? In the logistic regression analysis. The accuracy of the model was assessed with ROC curve. The Canalejo score was validated in200 patients that underwent OPCABG in “Ernesto Ché Guevara” Heart Institute in Villa Clara, Cuba. Results and conclusions: The risk factors that results significant (p=0,05) in the morbidity logistic regression analysis were: ejection fraction, renal failure, peripheral vascular disease, preoperative cardiopulmonary resuscitation, left main trunk disease associated with significant stenosis in the three coronary vessel, preoperative hemodynamic instability, and history of cerebrovascular disease with sequel. The Canalejo score show an area under the ROC curve of 0,80 (80%) (AU)

Valor de 6 escalas de riesgo para predecir mortalidad en la cirugía coronaria sin circulación extracorpórea / Value of 6 risk scores for predicting mortality in coronary bypass surgery

Los modelos de estratificación del riesgo quirúrgico en cirugia cardíaca han sido elaborados a partir de pacientes intervenidos con el uso de la circulación extracorpórea. Con el presente trabajo nos proponemos ver como se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulación extracorpórea. En el período comprendido entre enero de 1997 y diciembre del 2002, 762 pacientes fueron sometidos a cirugía de revascularización miocárdica sin el uso de la circulación extracorpórea (OPCABG) por el servicio de cirugía cardíaca del Complejo Hospitalario Juan Canalejo de A Coruña, Galicia, España. Hubo 25 fallecidos lo que representa un 3,3 por ciento de mortalidad. Los datos correspondientes a cada paciente fueron recogidos de forma prospectiva en la base de datos Apolo del Servicio de Cirugía Cardíaca. A cada uno de los pacientes le fueron calculados los siguientes scores de riesgo(Parsonnet 95, Parsonnet 97, Euroscore, Cleveland Clinic, Ontario y Francés). La comparación de diferentes escores para predecir mortalidad, se realizó por medio de curvas ROC(AU)

Evaluación preoperatoria del riesgo en la cirugía coronaria sin circulación extracorpórea / Preoperative assessment of risks: coronary bypass surgery

Los modelos de estratificación del riesgo quirúrgico en cirugía cardiaca han sido elaborados a partir de pacientes intervenidos con circulación extracorpórea. El objetivo del presente estudio es valorar como se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulación extracorpórea, así como conocer cuáles son los factores de riesgo predictores de complicaciones mayores y mortalidad en nuestros pacientes revascularizados mediante dicha técnica. Entre nero de 1997 y diciembre de 2002 se realizó cirugía de revascularización miocárdica sin el uso de circulación estracorpórea en un total de 762 pacientes consecutivos; de ellos, 61 (8 por ciento)presentaron complicaciones mayores y 25 (3,3 por ciento) murieron. A partir de variables recogidas de forma prospectiva, se calcularon mediante un análisis de regresión logística los factores predictores para complicaciones mayores y mortalidad. En cada uno de los pacientes se calcularon las escalas de riesgo Parsonnet 97, Euroscore, Cleveland, Ontario y Francesa. Mediante curvas ROC se comparó la capacidad de cada una de las escalas para predecir la mortalidad y la presencia de complicaciones mayores. En nuestra serie, las variables preoperatorias que aumentan significativamente el riesgo fueron:reanimación cardiopulmonar, la presencia de insuficiencia renal, la arteriopatía periférica, la presencia de enfermedad coronaria severa de tronco izquierdo en más de 3 vasos y la fracción de eyección deprimida. Las escalas de riesgo que mejor predicen la mortalidad y la presencia de complicaciones mayores fueron Parsonnet 95 y Euroscore(AU)

Valor de 6 escalas de riesgo para predecir mortalidad en la cirugía coronaria sin circulación extracorpórea / Value of six risk stratification models in cardiac surgery to predict mortality in coronary artery bypass grafting surgery without extracorporeal circulation

Objetivo: Los modelos de estratificación del riesgo quirúrgico en cirugía cardíaca han sido elaborados a partir de pacientes intervenidos con el uso de la circulación extracorpórea. Con el presente trabajo nos proponemos ver como se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulación extracorpórea (CEC). Método: En el período comprendido entre enero de 1997 y diciembre del 2002, 762 pacientes fueron sometidos a cirugía de revascularización miocárdica sin el uso de la circulación extracorpórea (OPCABG) por el servicio de cirugía cardíaca del Complejo Hospitalario Juan Canalejo de A Coruña, Galicia, España. Hubo 25 fallecidos lo que representa un 3,3% de mortalidad. Los datos correspondientes a cada paciente fueron recogidos de forma prospectiva en la base de datos Apolo del servicio de cirugía cardíaca. A cada uno de los pacientes le fueron calculados los siguientes scores de riesgo (Parsonnet 95, Parsonnet 97, Euroscore, Cleveland Clinic, Ontario y Francés). La comparación de diferentes escores para predecir mortalidad, se realizó por medio de curvas ROC. Resultados: Todos los scores mostraron diferencias estadísticamente significativas (p≤0,05) entre los vivos y los muertos. La probabilidad de muerte según los diferentes scores analizados no es lineal, sino que aumenta proporcionalmente con el incremento del valor del score. El score que mejor predice la mortalidad en nuestra serie es el Parsonnet 95, con un área bajo la curva del 90%, seguido del Euroscore y el Parsonnet 97 con un área bajo la curva del 86% y 82% Conclusión: Estos resultados nos permiten conocer que scores de riesgo que fueron diseñados con pacientes que fueron sometidos a cirugía cardíaca usando la CEC, pueden ser usados en los pacientes que serán sometidos a OPCABG (AU)

Objective: The risk stratification models have been developed in patients that underwent cardiac surgery using cardiopulmonary bypass and cardioplegic arrest. The aim of this study is to know how predict mortality six risk scores in patients that underwent coronary artery bypass grafting surgery without extracorporeal circulation (OPCABG). Methods: Between January 1, 1997 and December 30, 2002, 762 patients were submitted to OPCABG in the cardiac service of Juan Canalejo Hospital in A Coruña, Galicia, Spain. Twenty five patients (3,3%) died in the first month postoperative. The dates for each patient were collected in cardiac service Apolo database and were calculated the following risk scores: Parsonnet 95, Parsonnet 97, Euroscore, Cleveland Clinic, Ontario and Frances. The comparisons between different scores were made by ROC curves. Results: All risk scores showed statistic significant (p≤ 0,05) between alive and dead patients. The probability of dead is not lineal, but it is increase proportionality with the risk score value. The best score to predict mortality was Parsonnet 95 with an area under the ROC curve of 90%. Other scores that show a good value of ROC curve were Euroscore (0, 86) and Parsonnet 97 (0, 82). Conclusion: These results permit us to know that risk scores which were developed in patients that underwent cardiac surgery with cardiopulmonary bypass (CEC), can be used in patients that will undergo OPCABG (AU)

Evaluación preoperatoria del riesgo en la cirugía coronaria sin circulación extracorpórea / Preoperative risk evaluation in beating-heart coronary artery bypass surgery

Introducción y objetivos. Los modelos de estratificación del riesgo quirúrgico en cirugía cardíaca han sido elaborados a partir de pacientes intervenidos con circulación extracorpórea. El objetivo del presente estudio es valorar cómo se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulación extracorpórea, así como conocer cuáles son los factores de riesgo predictores de complicaciones mayores y mortalidad en nuestros pacientes revascularizados mediante dicha técnica.Pacientes y método. Entre enero de 1997 y diciembre de 2002 se realizó cirugía de revascularización miocárdica sin el uso de circulación extracorpórea en un total de 762 pacientes consecutivos; de ellos, 61 (8%) presentaron complicaciones mayores y 25 (3,3%) murieron. A partir de variables recogidas de forma prospectiva, se calcularon mediante un análisis de regresión logística los factores predictores para complicaciones mayores y mortalidad. En cada uno de los pacientes se calcularon las escalas de riesgo Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario y Francesa. Mediante curvas ROC se comparó la capacidad de cada una de las escalas para predecir la mortalidad y la presencia de complicaciones mayores.Resultados. En nuestra serie, las variables preoperatorias que aumentan significativamente el riesgo fueron: la resucitación cardiopulmonar, la presencia de insuficiencia renal, la arteriopatía periférica, la presencia de enfermedad coronaria severa de tronco izquierdo en más de 3 vasos y la fracción de eyección deprimida.Conclusiones. Las escalas de riesgo que mejor predicen la mortalidad y la presencia de complicaciones mayores fueron Parsonnet 95 y Euroscore

Introduction and objectives. Operative risk stratification scales for use in cardiac surgery have been developed for patients who undergo procedures using extracorporeal circulation. The aims of the present study were to investigate the use of six preoperative risk stratification scales in patients undergoing beating-heart surgery and to identify risk factors for major complications and mortality in our group of patients who underwent revascularization using this approach.Patients and method. Between January 1997 and December 2002, we performed 762 coronary artery bypass operations on the beating heart; 61 patients suffered major complications (8%) and 25 died (3.3%). Risk factors for major complications and death were identified using logistic regression analysis of prospectively collected data. The following risk scores were calculated for each patient: Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario, and French. Receiver operating characteristic curves were used to compare the ability of each scale to predict mortality and major complications.Results. In our patient group, the preoperative variables associated with increased risk were: need for cardiopulmonary resuscitation, renal dysfunction, peripheral vasculopathy, and the presence of severe left main coronary artery disease, three-vessel disease, or an impaired ejection fraction.Conclusions. Mortality and major complications were best predicted by the Parsonnet 95 and Euroscore scales

Incidencia, factores de riesgo e influencia sobre la supervivencia de las complicaciones infecciosas en el trasplante hepático / Incidence, risk factors and influence on survival of infectious complications in liver transplantation

INTRODUCCIÓN. El trasplante hepático es eficaz en pacientes con enfermedades hepáticas en situación terminal. La infección es una amenaza para la vida de los pacientes trasplantados. Los objetivos del estudio han sido estudiar la supervivencia general tras el trasplante hepático, la influencia en la supervivencia de las complicaciones infecciosas y determinar los factores de riesgo asociados con el primer episodio de infección (bacteriana, fúngica, fúngica invasora y enfermedad por citomegalovirus). MÉTODOS. Se han incluido 165 trasplantes realizados en 152 receptores en el período: mayo de 1994 hasta mayo de 1998. Se ha realizado un estudio descriptivo de 100 variables incluidas estratificadas según aspectos prequirúgicos, quirúrgicos y posquirúgicos, la determinación de las variables asociadas con la presencia de las diferentes infecciones se ha realizado con un análisis de regresión de Cox y el estudio de la supervivencia mediante la metodología de Kaplan-Meier. RESULTADOS. La infección se ha presentado en el 66 por ciento de los pacientes y se ha distribuido de la siguiente forma: viral (41,8 por ciento), bacteriana (33,9 por ciento), fúngica (20,6 por ciento) y fúngica invasora (4,2 por ciento). La supervivencia tras el trasplante ha sido del 90 por ciento al primer año y del 75 por ciento al cuarto año. Todas las infecciones han disminuido la supervivencia. Las variables asociadas con la presencia de las diferentes infecciones en el análisis multivariante han sido las siguientes; con la infección bacteriana, la diálisis, la ventilación mecánica y el tiempo de isquemia fría del injerto; con la infección fúngica; el número de horas de la cirugía y el valor de la albúmina plasmática antes del trasplante; con la infección fúngica invasora, el número de unidades de sangre transfundidas, el valor de la albúmina plasmática antes del trasplante y el retrasplante. La enfermedad por citomegalovirus se asoció en el análisis univariado con la infección fúngica y la infección fúngica invasora pero en el análisis multivariante no se encontró ninguna variable que incrementara el riesgo (AU)