¿Están alineados los planetas para que las enfermeras crucen el espejo? / Are planets lined up for nurses to cross the mirror?

Desde la publicación en el año 2010 del documento «La enfermería frente al espejo: mitos y realidades», la profesión enfermera ha realizado un trabajo de análisis y reconocimiento de sus mitos y realidades y es el momento en que necesariamente debe hacerse la pregunta de si ya está en mejores condiciones para dejar de mirarse en el espejo y, como Alicia, cruzar a través de él

Since the publication in 2010 of the document 'Nursing in front of the mirror: myths and realities', the nursing profession has worked hard to study and recognise its myths and realities. Now is the time to ask whether the profession is yet in a position to stop standing in front the looking glass and, like Alice, cross through

Are planets lined up for nurses to cross the mirror? / ¿Están alineados los planetas para que las enfermeras crucen el espejo?

Since the publication in 2010 of the document 'Nursing in front of the mirror: myths and realities', the nursing profession has worked hard to study and recognise its myths and realities. Now is the time to ask whether the profession is yet in a position to stop standing in front the looking glass and, like Alice, cross through.

Primary graft failure after heart transplantation: characteristics in a contemporary cohort and performance of the RADIAL risk score.

BACKGROUND: Primary graft failure (PGF) is the leading cause of early heart transplantation (HT) mortality. Our aim was to analyze PGF currently and explore the ability of a dedicated score for PGF risk stratification. METHODS: After applying a dedicated PGF definition, we analyzed its incidence, mortality, and associated factors in a multicenter cohort of 857 HTs performed in 2006 to 2009. We used the following criteria: recipient right (R) atrial pressure ≥ 10 mm Hg; age (A) ≥ 60 years; diabetes (D) mellitus, and inotrope (I) dependence; donor age (A) ≥ 30 years, and length (L) of ischemia ≥ 240 minutes to calculate the RADIAL score for PGF risk prediction. RESULTS: PGF incidence was 22%. The right ventricle was almost always affected, alone (45%) or as part of biventricular failure (47%). Mechanical circulatory support was used in 55%. Mortality attributable to PGF was 53% and extended through the third month after HT, but thereafter, PGF had little influence in long-term outcome. The RADIAL score was higher in PGF patients (2.78 ± 1.1 vs. 2.42 ± 1.1, p = 0.001) and stratified 3 groups with incremental PGF incidence: low risk (12.1%), intermediate risk (19.4%), and high risk (27.5%, p = 0.001). CONCLUSIONS: PGF had a strong impact, with an incidence of 22% and a mortality exceeding 50% that extends through the third post-HT month. The RADIAL score classified patients into 3 groups with incremental risk for PGF and may be useful for its prevention and early therapy.

Targeted antifungal prophylaxis in heart transplant recipients.

BACKGROUND: Antifungal prophylaxis after heart transplantation is usually targeted to high-risk recipients, but the duration is normally fixed and empirical. Our purpose was to assess the efficacy of a personalized prophylactic approach based on the duration of the risk factors. METHODS: In a prospective cohort, from 2003 to 2010, prophylaxis was only administered to patients with risk factors (13 of 133) and duration was personalized, starting with the risk factor and continued a median of 20 days after its resolution. RESULTS: Antifungal prophylaxis was prescribed only in 9.8% of the recipients and was effective in all but one patient who should have received a higher dose of caspofungin due to his obesity. Despite suffering an outbreak of invasive aspergillosis (IA) in the intensive care unit due to extremely high concentration of spores in the air (three cases with no personal risk factors), there was a reduction in the incidence of IA (8.6% vs. 2.2%; P=0.01) and Aspergillus-related mortality (5.75% vs. 1.5%; P=0.06). CONCLUSIONS: Targeted prophylaxis for IA in heart recipients provided only to patients with risk factors and maintained for a median of 20 days after their disappearance is effective and safe. A high environmental load of Aspergillus spores in the intensive care unit would also indicate the need for antifungal prophylaxis in all exposed patients.

Aspergilosis cardíaca en una paciente trasplantada de corazón / Cardiac invasive aspergillosis in a heart transplant recipient

Antecedentes: Los receptores de órgano sólido se consideran población de riesgo de aspergilosis invasora, afectándose fundamentalmente el pulmón o el sistema nervioso central. Objetivos: Describimos el caso de una paciente con aspergilosis cardíaca invasora probada 2 años después de un trasplante cardíaco y revisamos la aspergilosis cardíaca en el paciente trasplantado. Caso clínico: La paciente, de 52 años, recibió un trasplante de corazón. En el posoperatorio surgieron múltiples complicaciones, entre ellas el desarrollo de una aspergilosis invasora en la herida quirúrgica. La paciente reingresó 2 años después por disnea. En la tomografía computarizada toracoabdominal se observaron múltiples tromboem-bolismos pulmonares y una masa en la región retroxifoidea que invadía gran parte de la aurícula derecha y afecta-ba a la válvula tricúspide. En la biopsia de la masa se observaron hifas septadas invasoras, y se aisló posteriormente Aspergillusfumigatus. Las determinaciones de galactomanano sérico resultaron negativas. Se inició tratamiento con voriconazol y a los 2 meses acudió a revisión en buena situación clínica, pero con niveles séricos de voriconazol indetectables, aparentemente debido a la administración concomitante de omeprazol. La paciente está siendo se-guida ambulatoriamente y permanece en tratamiento con voriconazol y asintomática más de un año después. Conclusiones: La aspergilosis invasora con origen en el mediastino puede progresar y afectar al corazón. El uso de omeprazol puede conducir a la presencia de valores indetectables de voriconazol en suero. © 2011 Revista Iberoamericana de Micología. Publicado por Elsevier España, S.L. Todos los derechos reservados(AU)

Background: Solid organ transplant recipients are a population at risk of invasive aspergillosis. The lung and the central nervous system are usually affected. Objectives: We report the case of a patient with proven cardiac invasive aspergillosis two years after heart transplantation, and perform a review of cardiac aspergillosis in solid organ transplant recipients. Case report. A 52-year old woman received a heart transplant. Several complications appeared in the post-operative period, including the development of invasive aspergillosis in the surgical wound. She was readmitted two years later with dyspnea. A thoracic CT-scan revealed multiple lung embolisms and a mass in the retroxiphoid, invading the right atrium and the tricuspid valve. Septated hyphae invading this tissue were observed and Aspergillus fumiga-tus was subsequently isolated. Serum galactomannan determinations were negative. Antifungal therapy with vori-conazole was started. Two months later, the patient visited the hospital for a routine check-up control in good clinical condition, but with undetectable voriconazole serum levels. These levels were associated to the concomitant use of omeprazole. One year later, the patient was still receiving voriconazole and remained asymptomatic. Conclusions. Invasive aspergillosis affecting the mediastinum can progress and affect the heart tissues. The use of omeprazole may be associated with the undetectable voriconazole serum levels(AU)

[Cardiac invasive aspergillosis in a heart transplant recipient]. / Aspergilosis cardíaca en una paciente trasplantada de corazón.

BACKGROUND: Solid organ transplant recipients are a population at risk of invasive aspergillosis. The lung and the central nervous system are usually affected. OBJECTIVES: We report the case of a patient with proven cardiac invasive aspergillosis two years after heart transplantation, and perform a review of cardiac aspergillosis in solid organ transplant recipients. CASE REPORT: A 52-year old woman received a heart transplant. Several complications appeared in the post-operative period, including the development of invasive aspergillosis in the surgical wound. She was readmitted two years later with dyspnea. A thoracic CT-scan revealed multiple lung embolisms and a mass in the retroxiphoid, invading the right atrium and the tricuspid valve. Septated hyphae invading this tissue were observed and Aspergillus fumigatus was subsequently isolated. Serum galactomannan determinations were negative. Antifungal therapy with voriconazole was started. Two months later, the patient visited the hospital for a routine check-up control in good clinical condition, but with undetectable voriconazole serum levels. These levels were associated to the concomitant use of omeprazole. One year later, the patient was still receiving voriconazole and remained asymptomatic. CONCLUSIONS: Invasive aspergillosis affecting the mediastinum can progress and affect the heart tissues. The use of omeprazole may be associated with the undetectable voriconazole serum levels.

Bloodstream infections among heart transplant recipients.

BACKGROUND: Heart transplant (HT) recipients are prone to life-threatening infections, including bloodstream infection (BSI), but information on this topic is particularly scarce. METHODS: We studied 309 consecutive HT performed at our institution between 1988 and 2003. We assessed the characteristics of each episode of BSI, prophylaxis and immunosuppression used, and possible related factors. RESULTS: Sixty episodes of BSI occurred in 15.8% of all HT recipients. Rates of BSI/transplanted patient decreased progressively throughout the study period: 21.2%, 14.3%, and 7.5% in each 5-year period (P=0.03). BSI episodes occurred a median of 51 days after transplantation. The main BSI origins were: lower respiratory tract (23%), urinary tract (20%), and catheter-related-BSI (16%). Gram-negative organisms predominated (55.3%), followed by Gram-positive (44.6%). Mortality was 59.2%, with 12.2% directly attributable to BSI. Independent risk factors for BSI after HT were: hemodialysis (OR 6.5; 95% CI 3.2-13), prolonged intensive care unit stay (OR 3.6; 95% CI 1.6-8.1), and viral infection (OR 2.1; 95% CI 1.1-4). BSI was a risk factor for mortality (OR 1.8; 95% CI 1.2-2.8). CONCLUSION: BSIs have decreased in HT recipients, but still contribute to mortality, mainly if related to pneumonia or polymicrobial infections. Reduction of early postoperative complications and viral infections are amenable goals that may further reduce BSI in this population.

Risk factors of invasive aspergillosis after heart transplantation: protective role of oral itraconazole prophylaxis.

The study was designed to identify a subset of heart transplant (HT) recipients who could benefit from the administration of targeted antifungal prophylaxis and to evaluate the efficacy of oral itraconazole as the preventive drug. We have analyzed the risk factors for invasive aspergillosis (IA) in our entire population of HT recipients (1988-2002) and also the role of oral itraconazole prophylaxis that was provided to all patients since 1995 [400 mg q.d. of itraconazole oral (PO) for 3-6 months]. There were 24 cases of IA. Our main results indicate that the independent risk factors for IA after heart transplantation are: re-operation (RR 5.8; 95% CI 1.8-18, p=0.002), cytomegalovirus (CMV) disease (RR 5.2; 95% CI 2-13.9, p=0.001), post-transplant hemodialysis (RR 4.9; 95% CI 1.2-18, p=0.02), and the existence of an episode of IA in the HT program 2 months before or after the transplantation date (RR 4.6; 95% CI 1.5-14.4, p=0.007). Itraconazole prophylaxis showed an independent protective value against developing IA (RR 0.2; 95% CI 0.07-0.9, p=0.03) and also determined a significantly prolonged 1-year survival (RR 0.5; 95% CI 0.3-0.8, p=0.01). We believe that antifungal prophylaxis in heart transplant patients should be offered at least to patients with one or more of these predisposing conditions.