Assessing Outcomes of Patients Subject to Intensive Care to Facilitate Organ Donation: A Spanish Multicenter Prospective Study.

Intensive Care to facilitate Organ Donation (ICOD) consists of the initiation or continuation of intensive care measures in patients with a devastating brain injury (DBI) in whom curative treatment is deemed futile and death by neurological criteria (DNC) is foreseen, to incorporate organ donation into their end-of-life plans. In this study we evaluate the outcomes of patients subject to ICOD and identify radiological and clinical factors associated with progression to DNC. In this first prospective multicenter study we tested by multivariate regression the association of clinical and radiological severity features with progression to DNC. Of the 194 patients, 144 (74.2%) patients fulfilled DNC after a median of 25 h (95% IQR: 17-44) from ICOD onset. Two patients (1%) shifted from ICOD to curative treatment, both were alive at discharge. Factors associated with progression to DNC included: age below 70 years, clinical score consistent with severe brain injury, instability, intracranial hemorrhage, midline shift ≥5 mm and certain types of brain herniation. Overall 151 (77.8%) patients progressed to organ donation. Based on these results, we conclude that ICOD is a beneficial and efficient practice that can contribute to the pool of deceased donors.

One year follow-up on a randomized study investigating serratus anterior muscle and pectoral nerves type I block to reduced neuropathic pain descriptors after mastectomy.

Breast cancer is the second most common diagnosed type of cancer in women. Chronic neuropathic pain after mastectomy occurs frequently and is a serious health problem. In our previous single-center, prospective, randomized controlled clinical study, we demonstrated that the combination of serratus anterior plane block (SAM) and pectoral nerve block type I (PECS I) with general anesthesia reduced acute postoperative pain. The present report describes a prospective follow-up study of this published study to investigate the development of chronic neuropathic pain 12 months after mastectomy by comparing the use of general anesthesia alone and general anesthesia with SAM + PECS I. Additionally, the use of analgesic medication, quality of life, depressive symptoms, and possible correlations between plasma levels of interleukin (IL)-1 beta, IL-6, and IL-10 collected before and 24 h after surgery as predictors of pain and depression were evaluated. The results showed that the use of SAM + PECS I with general anesthesia reduced numbness, hypoesthesia to touch, the incidence of patients with chronic pain in other body regions and depressive symptoms, however, did not significantly reduce the incidence of chronic neuropathic pain after mastectomy. Additionally, there was no difference in the consumption of analgesic medication and quality of life. Furthermore, no correlation was observed between IL-1 beta, IL-6, and IL-10 levels and pain and depression. The combination of general anesthesia with SAM + PECS I reduced the occurrence of specific neuropathic pain descriptors and depressive symptoms. These results could promote the use of SAM + PECS I blocks for the prevention of specific neuropathic pain symptoms after mastectomy.Registration of clinical trial: The Research Ethics Board of the Hospital Sirio-Libanes/Brazil approved the study (CAAE 48721715.0.0000.5461). This study is registered at Registro Brasileiro de Ensaios Clinicos (ReBEC), and ClinicalTrials.gov, Identifier: NCT02647385.

Benefits in radical mastectomy protocol: a randomized trial evaluating the use of regional anesthesia.

Surgery is the first-line treatment for early, localized, or operable breast cancer. Regional anesthesia during mastectomy may offer the prevention of postoperative pain. One potential protocol is the combination of serratus anterior plane block (SAM block) with pectoral nerve block I (PECS I), but the results and potential benefits are limited. Our study compared general anesthesia with or without SAM block + PECS I during radical mastectomy with axillary node dissection and breast reconstruction using evaluations of pain, opioid consumption, side effects and serum levels of interleukin (IL)-1beta, IL-6 and IL-10. This is a prospective, randomized controlled trial. Fifty patients were randomized to general anesthesia only or general anesthesia associated with SAM block + PECS I (25 per group). The association of SAM block + PECS I with general anesthesia reduced intraoperative fentanyl consumption, morphine use and visual analog pain scale scores in the post-anesthetic care unit (PACU) and at 24 h after surgery. In addition, the anesthetic protocol decreased side effects and sedation 24 h after surgery compared to patients who underwent general anesthesia only. IL-6 levels increased after the surgery compared to baseline levels in both groups, and no differences in IL-10 and IL-1 beta levels were observed. Our protocol improved the outcomes of mastectomy, which highlight the importance of improving mastectomy protocols and focusing on the benefits of regional anesthesia.

Adherence to a predefined vaccination program in patients with inflammatory bowel disease / La adhesión a un programa de vacunación predefinido en pacientes con enfermedad inflamatoria intestinal

INTRODUCTION: The application of vaccination programs in patients with inflammatory bowel disease (IBD) is heterogeneous and generally deficient. As a result, adherence in these patients to a predefined vaccination program has not been clearly established. The aim of this study was to estimate adherence to a predefined vaccination program among patients with IBD and to identify the factors that may predict poor adherence. METHODS: All patients diagnosed with IBD and followed-up between January and March 2012 were referred to the Department of Preventive Medicine for evaluation of their immune status (with serological testing for hepatitis A, B and C viruses, varicella-zoster virus, mumps, rubella and measles), followed by vaccination based on the test results obtained and on the patient's vaccination history. The percentage of adherence to the vaccination program was determined, along with the factors associated with low adherence. RESULTS: A total of 153 patients with IBD (ulcerative colitis in 50.3% and Crohn's disease in 49.7%) were included (45.1% men and 54.9% women; mean age 43.30 ± 14.19 years, range 17-83). The vaccination program adherence rate was 84.3%. The factors associated with poor adherence were drugs related to IBD (patients not receiving immunosuppressants and/or biological agents showed lower adherence than those receiving these treatments; p = 0.021), adherence to medical treatment (poor adherence to treatment was also associated with poor adherence to vaccination; p = 0.016), and marital status (single, divorced or separated patients showed lower adherence than married individuals; p = 0.015). CONCLUSION: Adherence to vaccination is acceptable among patients with IBD. However, specific actions, such as optimization of patient information on the disease and emphasis on the need for adequate vaccination, are to improve adherence

INTRODUCCIÓN: La implantación de programas de vacunación en pacientes con enfermedad inflamatoria intestinal (EII) es heterogénea y en general, deficiente, por lo que no es bien conocida la adherencia de nuestros pacientes con EII a un programa de vacunación previamente establecido. El objetivo fue determinar la adherencia a un programa de vacunación establecido en nuestro centro en pacientes con diagnóstico de EII y definir qué factores pueden predecir una baja adherencia a dicho programa. MATERIAL Y MÉTODOS: Se derivaron al Servicio de Medicina Preventiva todos los pacientes con diagnóstico de EII revisados en consulta entre enero y marzo de 2012, con el fin de determinar su estado de inmunización (mediante la extracción de analítica con serologías del virus de la hepatitis A, B y C, virus varicela-zoster, parotiditis, rubeola y sarampión) y, posteriormente, ser vacunados teniendo en cuenta sus resultados así como el calendario vacunal previo. Se determinó el porcentaje de adherencia a dicho programa así como los factores relacionados con una baja adherencia. RESULTADOS: Se incluyeron 153 pacientes (45.1% hombres y 54.9% mujeres, con una edad media de 43.30±14.19 años, rango 17-83) con diagnóstico de EII (50.3% colitis ulcerosa y 49.7% enfermedad de Crohn). La adherencia al programa de vacunación fue del 84.3%. Los factores que se asociaron con una baja adherencia fueron: fármacos en relación con la EII (los pacientes que no tomaban inmunosupresores y/o biológicos presentaron una menor adherencia frente aquellos que sí los recibían, p 0.021), adherencia al tratamiento médico (aquellos con mala adherencia al tratamiento presentaron también baja adherencia a la vacunación, p 0.016), estado civil (solteros, divorciados o separados presentaron menor adherencia respecto a los casados, p 0.015). CONCLUSIÓN: La adherencia a la vacunación no es adecuada en pacientes con EII. Acciones específicas como la optimización de la información que se le proporciona al paciente acerca de su enfermedad y la necesidad de una adecuada vacunación, constituye un pilar fundamental para lograr mejorarla

Adherence to a predefined vaccination program in patients with inflammatory bowel disease.

INTRODUCTION: The application of vaccination programs in patients with inflammatory bowel disease (IBD) is heterogeneous and generally deficient. As a result, adherence in these patients to a predefined vaccination program has not been clearly established. The aim of this study was to estimate adherence to a predefined vaccination program among patients with IBD and to identify the factors that may predict poor adherence. METHODS: All patients diagnosed with IBD and followed-up between January and March 2012 were referred to the Department of Preventive Medicine for evaluation of their immune status (with serological testing for hepatitis A, B and C viruses, varicella-zoster virus, mumps, rubella and measles), followed by vaccination based on the test results obtained and on the patient's vaccination history. The percentage of adherence to the vaccination program was determined, along with the factors associated with low adherence. RESULTS: A total of 153 patients with IBD (ulcerative colitis in 50.3% and Crohn's disease in 49.7%) were included (45.1% men and 54.9% women; mean age 43.30±14.19 years, range 17-83). The vaccination program adherence rate was 84.3%. The factors associated with poor adherence were drugs related to IBD (patients not receiving immunosuppressants and/or biological agents showed lower adherence than those receiving these treatments; p=0.021), adherence to medical treatment (poor adherence to treatment was also associated with poor adherence to vaccination; p=0.016), and marital status (single, divorced or separated patients showed lower adherence than married individuals; p=0.015). CONCLUSION: Adherence to vaccination is acceptable among patients with IBD. However, specific actions, such as optimization of patient information on the disease and emphasis on the need for adequate vaccination, are to improve adherence.

Niveles de propéptido aminoterminal de procolágeno tipos I y III y gravedad de la enfermedad pulmonar intersticial en mujeres mexicanas con esclerosis sistémica progresiva / Procollagen Type I and III Aminoterminal Propeptide Levels and Severity of Interstitial Lung Disease in Mexican Women With Progressive Systemic Sclerosis

Antecedentes: La enfermedad pulmonar intersticial (EPI) es una complicación frecuente en la esclerosis sistémica (ES) progresiva, presente en el 25-90% de los pacientes. Objetivo: Evaluar si los niveles séricos de propéptido aminoterminal de procolágeno tipos i y iii (PINP y PIIINP) se correlacionan con la gravedad de la EPI en mujeres mexicanas con ES. Métodos: En 33 pacientes con ES se evaluaron las características de la enfermedad, anticuerpos antitopoisomerasa (topo i), pruebas de función pulmonar y tomografía computarizada de alta resolución (TCAR). Diecinueve pacientes tenían ES + EPI y 14 no presentaban afectación pulmonar (ES sin EPI). Se compararon con 45 controles sanos. Se evaluaron PINP y PIIINP en los 3 grupos. Resultados: El grupo ES tuvo mayores niveles de PINP y PIIINP que el control (p = 0,001 y p < 0,001, respectivamente). Las pacientes ES + EPI habían presentado la enfermedad más años que las ES sin EPI (p = 0,005), tenían mayor puntuación en el índice modificado de Rodnan (p < 0,001), puntuación alta en el índice de evaluación de discapacidad (p < 0,001), mayores niveles de antitopoisomerasa i (p < 0,001), PINP (49,28 ± 28,63 vs. 32,12 ± 18,58 μg/l, p = 0,05), y PIIINP (4,33 ± 1,03 vs. 2,67 ± 1,26 μg/l, p < 0,001). La gravedad de la EPI en TACAR se correlacionó con los niveles de PINP (r = 0,388, p = 0,03) y PIIINP (p = 0,594, p < 0,001). En el análisis ajustado, la gravedad de la EPI se asoció con la duración de la enfermedad (p = 0,037) y con los niveles de PIIINP (p = 0,038) y de antitopoisomerasa i (p = 0,045). Conclusiones: El PINP y el PIIINP son marcadores útiles para la ES + EPI grave. Esto apoya su uso clínico para el seguimiento de esta complicación

Background: Interstitial lung disease (ILD) is a frequent complication in progressive systemic sclerosis (SSc), being present in 25% to 90% of cases. Objectives: To evaluate whether serum levels of procollagen type i and iii aminoterminal propeptide (PINP and PIIINP) correlate with severity and patterns of ILD in Mexican women with SSc. Methods: Thirty three SSc patients were assessed for disease characteristics and anti-topoisomerase antibodies (topo i), and also underwent pulmonary function tests and high-resolution computed tomography (HRCT). Nineteen patients had ILD + SSc, and 14 had no lung involvement (no ILD-SSc); data were compared with those from 45 healthy controls. PINP and PIIINP were assessed in all 3 groups. Results: Patients with SSc had higher PINP and PIIINP vs controls (P = .001, P < .001, respectively). Compared to no ILD-SSc patients, those with ILD + SSc had longer disease duration in years (P = .005), higher modified Rodnan skin score (P < .001), higher Health Assessment Questionnaire-Disability-Index scores (P < .001), higher topo i U/mL (P < .001), PINP (49.28 ± 28.63 vs. 32.12 ± 18.58 g/L, P = .05), and PIIINP (4.33 ± 1.03 vs. 2.67 ± 1.26 g/L, P < .001) levels. ILD severity based on total HRCT correlated with PINP (r = .388, P = .03) and PIIINP (P = .594, P < .001). On adjusted analysis, ILD severity was associated with disease duration (P = .037), PIIINP (P = .038), and topo i (P = .045). Conclusions: PINP and PIIINP are useful markers for severe ILD + SSc, suggesting they could play a role in the follow-up of this complication in SSc

Procollagen Type I and III Aminoterminal Propeptide Levels and Severity of Interstitial Lung Disease in Mexican Women With Progressive Systemic Sclerosis.

BACKGROUND: Interstitial lung disease (ILD) is a frequent complication in progressive systemic sclerosis (SSc), being present in 25% to 90% of cases. OBJECTIVES: To evaluate whether serum levels of procollagen typei and iii aminoterminal propeptide (PINP and PIIINP) correlate with severity and patterns of ILD in Mexican women with SSc. METHODS: Thirty three SSc patients were assessed for disease characteristics and anti-topoisomerase antibodies (topoi), and also underwent pulmonary function tests and high-resolution computed tomography (HRCT). Nineteen patients had ILD+SSc, and 14 had no lung involvement (no ILD-SSc); data were compared with those from 45 healthy controls. PINP and PIIINP were assessed in all 3 groups. RESULTS: Patients with SSc had higher PINP and PIIINP vs controls (P=.001, P<.001, respectively). Compared to no ILD-SSc patients, those with ILD+SSc had longer disease duration in years (P=.005), higher modified Rodnan skin score (P<.001), higher Health Assessment Questionnaire-Disability-Index scores (P<.001), higher topoi U/mL (P<.001), PINP (49.28±28.63 vs. 32.12±18.58µg/L, P=.05), and PIIINP (4.33±1.03 vs. 2.67±1.26µg/L, P<.001) levels. ILD severity based on total HRCT correlated with PINP (r=.388, P=.03) and PIIINP (P=.594, P<.001). On adjusted analysis, ILD severity was associated with disease duration (P=.037), PIIINP (P=.038), and topoi (P=.045). CONCLUSIONS: PINP and PIIINP are useful markers for severe ILD+SSc, suggesting they could play a role in the follow-up of this complication in SSc.

[Adequate rate of response to hepatitis B virus vaccination in patients with inflammatory bowel disease]. / Eficacia de la vacuna contra el virus de la hepatitis B en pacientes con enfermedad inflamatoria intestinal.

BACKGROUND AND OBJECTIVE: Patients with Inflammatory Bowel Disease (IBD) may have an increased risk of developing hepatitis B virus (HB) infection. Invasive procedures such as colonoscopies and surgery might be some of the reasons for this. Moreover, the use of immunosuppressors may reactivate a latent infection. We assessed the immune status among IBD patients receiving HB vaccine and the circumstances that predicted its results. AIMS AND METHODS: Serological markers of B and C hepatitis virus in patients with IBD who were referred for consultation were assessed since 2006. The subsequent determination of antibodies against superficial antigen (HBsAb) could differentiate between responders and non responders to the vaccine and an adequate immunity to HB was defined as higher than 10mUI/ml. RESULTS: One hundred and twenty nine patients were included in our study. Fifty-six (43,4%) patients had received immunosuppressive medication before the first vaccine dose. Notably, 85 (65.9%) patients had inadequate levels of HBsAb: 36 had no detectable levels and 49 had less than 10mUI/ml. Younger patients had a better immunity response than older patients (30.91+/-14.8 vs 39.91+/-14.2) (p<0.001). CONCLUSION: More than half of the patients had a suboptimal serologic response after vaccination. Only the younger group showed a better rate of response. It was not demonstrated whether an additional fourth dose of vaccination or a complete revaccination improved the rate of responders.

Eficacia de la vacuna contra el virus de la hepatitis B en pacientes con enfermedad inflamatoria intestinal / Adequate rate of response to hepatitis B virus vaccination in patients with inflammatory bowel disease

Fundamento y objetivo: Aunque parece que no hay un aumento en la prevalencia de infección por el virus de la hepatitis B (VHB) en pacientes con enfermedad inflamatoria intestinal (EII), se especula que la necesidad de exploraciones invasivas e intervenciones quirúrgicas sitúa a estos pacientes dentro de un grupo de riesgo para contraer esta infección. Además, el uso cada vez más frecuente de inmunomoduladores puede conducir a una reactivación vírica latente. El objetivo de este trabajo fue evaluar la eficacia de la vacuna contra el VHB en pacientes con EII y las circunstancias que pueden influir en su resultado. Pacientes y métodos: Desde el año 2006, se determinaron los marcadores serológicos de los virus B y C de la hepatitis en los pacientes con EII atendidos en esta consulta médica de forma consecutiva. La posterior determinación de los anticuerpos contra el antígeno de superficie del VHB (anti-HBs) diferenció entre reactivos o no a la vacuna, y se consideró como respuesta valores iguales o superiores a≥10mUI/ml. Resultados: Se incluyó en el estudio a 129 pacientes. Cincuenta y seis pacientes (43,4%) habían recibido algún tratamiento inmunomodulador previo a la vacuna. En 85 pacientes (65,9%) la vacuna no indujo una respuesta adecuada: 36 pacientes no crearon anti-HBs y en 49 pacientes se desarrollaron títulos inferiores a 10mUI/ml. El único factor implicado en la respuesta de la vacuna fue la edad, de forma que en los pacientes más jóvenes la eficacia de la vacuna fue mayor (media de 30,91 [14,8] frente a 39,91 [14,2] años, p<0,001). Conclusiones: En más de la mitad de los pacientes con EII no se desarrolló una respuesta adecuada a la vacuna del VHB. El único factor relacionado con una mejor eficacia fue la edad más joven. Queda por demostrar si una cuarta dosis o si la revacunación completa aumentarían esta tasa de respuesta (AU)

Background and objective: Patients with Inflammatory Bowel Disease (IBD) may have an increased risk of developing hepatitis B virus (HB) infection. Invasive procedures such as colonoscopies and surgery might be some of the reasons for this. Moreover, the use of immunosuppressors may reactivate a latent infection. We assessed the immune status among IBD patients receiving HB vaccine and the circumstances that predicted its results. Aims and methods: Serological markers of B and C hepatitis virus in patients with IBD who were referred for consultation were assessed since 2006. The subsequent determination of antibodies against superficial antigen (HBsAb) could differentiate between responders and non responders to the vaccine and an adequate immunity to HB was defined as higher than 10mUI/ml. Results: One hundred and twenty nine patients were included in our study. Fifty-six (43,4%) patients had received immunosuppressive medication before the first vaccine dose. Notably, 85 (65.9%) patients had inadequate levels of HBsAb: 36 had no detectable levels and 49 had less than 10mUI/ml. Younger patients had a better immunity response than older patients (30.91±14.8 vs 39.91±14.2) (p<0.001). Conclusion: More than half of the patients had a suboptimal serologic response after vaccination. Only the younger group showed a better rate of response. It was not demonstrated whether an additional fourth dose of vaccination or a complete revaccination improved the rate of responders (AU)