Comparison of the 2022 and 2017 European LeukemiaNet risk classifications in a real-life cohort of the PETHEMA group.

Next-Generation Sequencing is needed for the accurate genetic risk stratification of acute myeloid leukemia according to European LeukemiaNet (ELN) guidelines. We validated and compared the 2022 ELN risk classification in a real-life cohort of 546 intensively and 379 non-intensively treated patients. Among fit patients, those aged ≥65 years old showed worse OS than younger regardless risk classification. Compared with the 2017 classification, 14.5% of fit patients changed the risk with the 2022 classification, increasing the high-risk group from 44.3% to 51.8%. 3.7% and 0.9% FLT3-ITD mutated patients were removed from the favorable and adverse 2017 categories respectively to 2022 intermediate risk group. We suggest that midostaurin therapy could be a predictor for 3 years OS (85.2% with vs. 54.8% without midostaurin, P = 0.04). Forty-seven (8.6%) patients from the 2017 intermediate group were assigned to the 2022 adverse-risk group as they harbored myelodysplasia (MDS)-related mutations. Patients with one MDS-related mutation did not reach median OS, while patients with ≥2 mutations had 13.6 months median OS (P = 0.002). Patients with TP53 ± complex karyotype or inv(3) had a dismal prognosis (7.1 months median OS). We validate the prognostic utility of the 2022 ELN classification in a real-life setting providing supportive evidences to improve risk stratification guidelines.

Physiologic Voice Rehabilitation Based on Water Resistance Therapy With Connected Speech in Subjects With Vocal Fatigue.

PURPOSE: The present study aimed to assess the effectiveness of a physiologic voice therapy program based on water resistance therapy (WRT) exercises including connected speech in a group of subjects with voice complaints (vocal effort and fatigue). METHODS: Twenty-four participants with behavioral dysphonia were randomly assigned to one of two treatment groups: (1) voice treatment with WRT plus vocal hygiene program (n = 12), and (2) vocal hygiene program only (n = 12). Laryngoscopic assessment was performed in all subjects. Before and after voice therapy, participants underwent aerodynamic and electroglottographic assessment. The Voice Handicap Index (VHI) and self-assessment of resonant voice were also performed. The treatment included six voice therapy sessions. For the experimental group, the exercises consisted of a sequence of seven phonatory tasks performed with two different voice training devices (PocketVox and MaskVox). Comparison for all variables was performed between experimental group and control group. RESULTS: Significant differences were found for experimental group for VHI physical subscale, and self-perceived resonant voice when comparing pre-post conditions. A strong negative correlation between self-perceived resonant voice and VHI physical sub-score was also reported. No significant differences were found for instrumented variables. CONCLUSION: Physiologic voice therapy based on WRT exercises including connected speech seems to be an effective tool to improve self-perceived voice in subjects diagnosed with voice complaints. Apparently, changes are more prone to occur in perceptual variables related with physical discomfort associate with voice production. A reduction in phonatory effort and perceptual aspects of vocal fatigue are the main improvements.

Preoperative Omega-6/Omega-3 Fatty Acid Ratio Could Predict Postoperative Outcomes in Patients with Surgically Resected Non-Small-Cell Lung Cancer.

Introduction: The aim of this study was to determine whether preoperative nutritional status and inflammatory status, specifically polyunsaturated acids and the omega 6/3 ratio, would affect postoperative outcomes and complications in patients with lung cancer undergoing lung resection. Methods: This prospective observational study included 68 patients with early-stage non-small-cell lung cancer who were candidates for radical surgery. A complete nutritional assessment was performed. The primary study variable was postoperative complications and mortality in the first 30 days. Descriptive, bivariate, and logistic regression analyses were carried out. Results: A total of 50 men (73.53%) and 18 women (26.47%) underwent surgery, with a median age of 64.2 (±9.74) years. The mean omega 6/3 ratio was 17.39 (±9.45). A complication occurred in 39.7% of the study sample (n = 27), the most common being persistent air leak in 23.53% (n = 16). After performing the bivariate analysis, the only variable that remained significant was the omega 6/3 ratio; we observed that it had a prognostic value for persistent air leak (p = 0.001) independent of age, sex, comorbidity, preoperative respiratory function, and approach or type of surgery. The remaining nutritional and inflammatory markers did not have a statistically significant association (p > 0.05) with postoperative complications. However, this significance was not maintained in the multivariate analysis by a small margin (p = 0.052; 95% CI: 0.77-1.41). Conclusions: Omega 6/3 ratio may be a prognostic factor for air leak, independent of the patient's clinical and pathological characteristics.

Prognostic significance of FLT3-ITD length in AML patients treated with intensive regimens.

FLT3-ITD mutations are detected in approximately 25% of newly diagnosed adult acute myeloid leukemia (AML) patients and confer an adverse prognosis. The FLT3-ITD allelic ratio has clear prognostic value. Nevertheless, there are numerous manuscripts with contradictory results regarding the prognostic relevance of the length and insertion site (IS) of the FLT3-ITD fragment. We aimed to assess the prognostic impact of these variables on the complete remission (CR) rates, overall survival (OS) and relapse-free survival (RFS) of AML patients with FLT3-ITDmutations. We studied the FLT3-ITD length of 362 adult AML patients included in the PETHEMA AML registry. We tried to validate the thresholds of ITD length previously published (i.e., 39 bp and 70 bp) in intensively treated AML patients (n = 161). We also analyzed the mutational profile of 118 FLT3-ITD AML patients with an NGS panel of 39 genes and correlated mutational status with the length and IS of ITD. The AUC of the ROC curve of the ITD length for OS prediction was 0.504, and no differences were found when applying any of the thresholds for OS, RFS or CR rate. Only four out of 106 patients had ITD IS in the TKD1 domain. Our results, alongside previous publications, confirm that FLT3-ITD length lacks prognostic value and clinical applicability.

Evolving patterns of care and outcomes in relapsed/refractory FLT3 mutated acute myeloid leukemia adult patients.

We have analyzed treatment patterns and outcomes of relapsed/refractory(R/R) FLT3mut AML adult patients registered in our institutional data base between 1998 and 2018. Overall, 147 patients were evaluable: 34 from 1998 to 2009, 113 from 2010 to 2018. Salvage treatments were intensive chemotherapy (n = 25, 74%), and supportive care (n = 9, 26%) in the 1998-2009 period, and intensive chemotherapy (n = 63, 56%), hypomethylating agent (n = 7, 6%), low-dose cytarabine-based (n = 8, 7%), clinical trial (n = 16, 14%) and supportive care (n = 19, 17%) in the 2010-2018 period. Complete remission (CR) or with incomplete recovery (CRi) rate was 44%, 49% among patients treated intensively (vs 30% with non-intensive p = 0.005). Median overall survival since first R/R was 5.8 months, and 16.3 months in subjects receiving an allo-HSCT in CR/CRi after first salvage (vs 3.8 in the remaining patients p < 0.0001). Clinical outcomes of R/R FLT3mut AML remain unsatisfactory. Inclusion in clinical trials and expanding options could lead to improved outcomes.

Networking for advanced molecular diagnosis in acute myeloid leukemia patients is possible: the PETHEMA NGS-AML project

Next-Generation Sequencing has recently been introduced to efficiently and simultaneously detect genetic variations in acute myeloid leukemia. However, its implementation in the clinical routine raises new challenges focused on the diversity of assays and variant reporting criteria. To overcome this challenge, the PETHEMA group established a nationwide network of reference laboratories aimed to deliver molecular results in the clinics. We report the technical cross-validation results for next-generation sequencing panel genes during the standardization process and the clinical validation in 823 samples of 751 patients with newly diagnosed or refractory/relapse acute myeloid leukemia. Two cross-validation rounds were performed in seven nationwide reference laboratories in order to reach a consensus regarding quality metrics criteria and variant reporting. In the pre-standardization cross-validation round, an overall concordance of 60.98% was obtained with a great variability in selected genes and conditions across laboratories. After consensus of relevant genes and optimization of quality parameters the overall concordance rose to 85.57% in the second cross-validation round. We show that a diagnostic network with harmonized next-generation sequencing analysis and reporting in seven experienced laboratories is feasible in the context of a scientific group. This cooperative nationwide strategy provides advanced molecular diagnostic for acute myeloid leukemia patients of the PETHEMA group.

Clinical performance of the Osia™ system, a new active osseointegrated implant system. Results from a prospective clinical investigation.

Background: Bone-conduction hearing implants are standard of care devices.Aims/Objectives: Evaluation of a new active magnetic bone-conduction hearing implant: Cochlear Osia™ system.Material and methods: This device uses a transcutaneous connection between an external sound-processor and an osseointegrated implant that generates vibrations using a piezoelectricity-based internal bone-conduction system. Nine patients with conductive-hearing loss were implanted. Surgical efficacy, hearing performance and quality-of-life were evaluated. Hearing performance in quiet and in noise was compared with unaided hearing and hearing with the Baha 5 Power® Sound Processor on a softband.Results: Surgery and healing were uneventful. Statistically significant improvements in audibility, speech-understanding, speech-recognition and quality-of-sound in noise and quiet were found for the Osia™ compared to preoperative unaided hearing and aided hearing with the Baha 5 Power® Sound Processor on a softband. The active vibration system provided improvement at low and high frequencies. At 6 months postoperatively, all patients continue to use the device.Conclusions and significance: The Osia™ is safe and effective, improving speech-recognition in quiet and in noise, at low and high frequencies, thus delivering better quality-of-hearing than passive devices.

Chromosomal Abnormalities and Prognosis in NPM1-Mutated Acute Myeloid Leukemia: A Pooled Analysis of Individual Patient Data From Nine International Cohorts.

PURPOSE: Nucleophosmin 1 (NPM1) mutations are associated with a favorable prognosis in acute myeloid leukemia (AML) when an internal tandem duplication (ITD) in the fms-related tyrosine kinase 3 gene (FLT3) is absent (FLT3-ITDneg) or present with a low allelic ratio (FLT3-ITDlow). The 2017 European LeukemiaNet guidelines assume this is true regardless of accompanying cytogenetic abnormalities. We investigated the validity of this assumption. METHODS: We analyzed associations between karyotype and outcome in intensively treated patients with NPM1mut/FLT3-ITDneg/low AML who were prospectively enrolled in registry databases from nine international study groups or treatment centers. RESULTS: Among 2,426 patients with NPM1mut/FLT3-ITDneg/low AML, 2,000 (82.4%) had a normal and 426 (17.6%) had an abnormal karyotype, including 329 patients (13.6%) with intermediate and 83 patients (3.4%) with adverse-risk chromosomal abnormalities. In patients with NPM1mut/FLT3-ITDneg/low AML, adverse cytogenetics were associated with lower complete remission rates (87.7%, 86.0%, and 66.3% for normal, aberrant intermediate, and adverse karyotype, respectively; P < .001), inferior 5-year overall (52.4%, 44.8%, 19.5%, respectively; P < .001) and event-free survival (40.6%, 36.0%, 18.1%, respectively; P < .001), and a higher 5-year cumulative incidence of relapse (43.6%, 44.2%, 51.9%, respectively; P = .0012). These associations remained in multivariable mixed-effects regression analyses adjusted for known clinicopathologic risk factors (P < .001 for all end points). In patients with adverse-risk chromosomal aberrations, we found no significant influence of the NPM1 mutational status on outcome. CONCLUSION: Karyotype abnormalities are significantly associated with outcome in NPM1mut/FLT3-ITDneg/low AML. When adverse-risk cytogenetics are present, patients with NPM1mut share the same unfavorable prognosis as patients with NPM1 wild type and should be classified and treated accordingly. Thus, cytogenetic risk predominates over molecular risk in NPM1mut/FLT3-ITDneg/low AML.

A prognostic model for survival after salvage treatment with FLAG-Ida +/- gemtuzumab-ozogamicine in adult patients with refractory/relapsed acute myeloid leukaemia.

The combination of fludarabine, cytarabine, idarubicin, and granulocyte colony-stimulating factor (FLAG-Ida) is widely used in relapsed/refractory acute myeloid leukaemia (AML). We retrospectively analysed the results of 259 adult AML patients treated as first salvage with FLAG-Ida or FLAG-Ida plus Gentuzumab-Ozogamicin (FLAGO-Ida) of the Programa Español de Tratamientos en Hematología (PETHEMA) database, developing a prognostic score system of survival in this setting (SALFLAGE score). Overall, 221 patients received FLAG-Ida and 38 FLAGO-Ida; 92 were older than 60 years. The complete remission (CR)/CR with incomplete blood count recovery (CRi) rate was 51%, with 9% of induction deaths. Three covariates were associated with lower CR/CRi: high-risk cytogenetics and t(8;21) at diagnosis, no previous allogeneic stem cell transplantation (allo-SCT) and relapse-free interval <1 year. Allo-SCT was performed in second CR in 60 patients (23%). The median overall survival (OS) of the entire cohort was 0·7 years, with 22% OS at 5-years. Four independent variables were used to construct the score: cytogenetics, FLT3-internal tandem duplication, length of relapse-free interval and previous allo-SCT. Using this stratification system, three groups were defined: favourable (26% of patients), intermediate (29%) and poor-risk (45%), with an expected 5-year OS of 52%, 26% and 7%, respectively. The SALFLAGE score discriminated a subset of patients with an acceptable long-term outcome using FLAG-Ida/FLAGO-Ida regimen. The results of this retrospective analysis should be validated in independent external cohorts.

Oxidative lung injury correlates with one-lung ventilation time during pulmonary lobectomy: a study of exhaled breath condensate and blood.

OBJECTIVES: During lung lobectomy, the operated lung is collapsed and hypoperfused; oxygen deprivation is accompanied by reactive hypoxic pulmonary vasoconstriction. After lung lobectomy, ischaemia present in the collapsed state is followed by expansion-reperfusion and lung injury attributed to the production of reactive oxygen species. The primary objective of this study was to investigate the time course of several markers of oxidative stress simultaneously in exhaled breath condensate and blood and to determine the relationship between oxidative stress and one-lung ventilation time in patients undergoing lung lobectomy. METHODS: This single-centre, observational, prospective study included 28 patients with non-small-cell lung cancer who underwent lung lobectomy. We measured the levels of hydrogen peroxide, 8-iso-PGF2α, nitrites plus nitrates and pH in exhaled breath condensate (n = 25). The levels of 8-iso-PGF2α and nitrites plus nitrates were also measured in blood (n = 28). Blood samples and exhaled breath condensate samples were collected from all patients at five time points: preoperatively; during one-lung ventilation, immediately before resuming two-lung ventilation; immediately after resuming two-lung ventilation; 60 min after resuming two-lung ventilation and 180 min after resuming two-lung ventilation. RESULTS: Both exhaled breath condensate and blood exhibited significant and simultaneous increases in oxidative-stress markers immediately before two-lung ventilation was resumed. However, all these values underwent larger increases immediately after resuming two-lung ventilation. In both exhaled breath condensate and blood, marker levels significantly and directly correlated with the duration of one-lung ventilation immediately before resuming two-lung ventilation and immediately after resuming two-lung ventilation. Although pH significantly decreased in exhaled breath condensate immediately after resuming two-lung ventilation, these pH values were inversely correlated with the duration of one-lung ventilation. CONCLUSIONS: During lung lobectomy, the operated lung is collapsed and oxidative injury occurs, with the levels of markers of oxidative stress increasing simultaneously in exhaled breath condensate and blood during one-lung ventilation. These increases were larger after resuming two-lung ventilation. Increases immediately before resuming two-lung ventilation and immediately after resuming two-lung ventilation were directly correlated with the duration of one-lung ventilation.

Pharmacological profiles of acute myeloid leukemia treatments in patient samples by automated flow cytometry: a bridge to individualized medicine.

BACKGROUND: We have evaluated the ex vivo pharmacology of single drugs and drug combinations in malignant cells of bone marrow samples from 125 patients with acute myeloid leukemia using a novel automated flow cytometry-based platform (ExviTech). We have improved previous ex vivo drug testing with 4 innovations: identifying individual leukemic cells, using intact whole blood during the incubation, using an automated platform that escalates reliably data, and performing analyses pharmacodynamic population models. PATIENTS AND METHODS: Samples were sent from 24 hospitals to a central laboratory and incubated for 48 hours in whole blood, after which drug activity was measured in terms of depletion of leukemic cells. RESULTS: The sensitivity of single drugs is assessed for standard efficacy (EMAX) and potency (EC50) variables, ranked as percentiles within the population. The sensitivity of drug-combination treatments is assessed for the synergism achieved in each patient sample. We found a large variability among patient samples in the dose-response curves to a single drug or combination treatment. CONCLUSION: We hypothesize that the use of the individual patient ex vivo pharmacological profiles may help to guide a personalized treatment selection.

Incidence, risk factors, and outcome of bacteremia following autologous hematopoietic stem cell transplantation in 720 adult patients.

Bacteremia is the most frequent infectious complication during neutropenia in patients receiving autologous hematopoietic stem cell transplantation (ASCT). The objective of this study was to analyze the incidence, characteristics, risk factors, and outcome of bacteremia during the early period after ASCT. A total of 720 patients undergoing ASCT in two observational prospective consecutive multicenter studies of the Programa Español para el Tratamiento de las Hemopatías group were analyzed. Bacteremia occurred in 20 % of patients. Coagulase-negative Staphylococcus was the most frequent (66 %) among the gram-positive agents and Escherichia coli (49 %) among the gram-negative agents. Multivariate analysis showed that the length of neutropenia <1 × 10(9)/L (more than 9 days) [relative risk (RR) of 2.6, p < 0.001] was the sole risk factor for overall bacteremia. We identified the length of neutropenia <1 × 10(9)/L (more than 9 days) (RR 4.98, p < 0.001) and the use of prophylactic fluoroquinolones (RR 0.46, p < 0.01) as specific risk factors for gram-negative bacteremia. Risk factors for gram-positive bacteremia were the use of total parenteral nutrition (RR 1.92, p < 0.01) and deep neutropenia (<0.1 × 10(9)/L), with duration over 5 days (RR 1.67, p < 0.027). Bacteremia showed an increased morbidity with no impact on neither overall nor infectious related mortality. The identification of such risk factors may be helpful to implement prophylactic and therapeutic risk-adapted strategies to reduce the incidence of bacteremia in ASCT.

Airway pressure curve: a good tool to measure neural inspiratory time?

BACKGROUND: Considerable asynchrony during pressure-support ventilation has been reported. While the beginning of active inspiration is usually identifiable in the airway pressure (Paw) curve (the inspiratory trigger), there is still a need for accurate, non-invasive methods to identify the end of inspiration. To test the hypothesis that inspiration, particularly the end of inspiration, can be estimated from the Paw curve, we compared indirect measurements based on Paw with simultaneous direct electromyography of the diaphragm (EMGdi). METHODS: We prospectively studied 10 patients during the weaning period after cardiac surgery. Inspiratory pressure support was set at 20, 15, 10, and 5 cm H(2)O; 25 respiratory cycles were analyzed at each pressure level. Recording of the electromyogram was obtained with electrodes inserted into the diaphragm during surgery. RESULTS: The start and end of inspiration were identified in the Paw curve in 99% and 98% of the 1000 cycles analyzed, respectively, and were coincident with the electromyogram in 62% and 53% of the cycles, respectively. The inspiratory time estimated from the Paw curve was well correlated (r=0.94, P<0.0001) with the electromyogram. CONCLUSION: The end of neural inspiration (EMGdi) can be easily and with little error recognized from the Paw curve alone in patients with normal ventilatory mechanics who receive pressure-support ventilation.

Aporte del estudio endoscópico de la deglución en niños con limitaciones neurológicas / Fiberoptic endoscopic evaluation of swallowing in children with neurologic impairments

Children with neurological disabilities are a healthcare problem with a growing incidence and require a multidisciplinary team for a proper manage. They frequently show swallowing disorders (sD) that must be suspected, diagnosed and treated by specialists. The sD study has several tools that have evolved over time. One of such tools is the fiberoptic endoscopic evaluation of swallowing (Fees). Since its appearance 20 years ago up to our days, Fees has been validated for the study of pharyngeal swallow. Fees are a standardized and systematic study that permits to evaluate the swallowing process through a direct visualization of the upper airways with a nasal flexible endoscopy. Besides the proper equipment, it also requires a full knowledge of pediatric anatomy and training, which can limit its use. It can be easily transported. It does not use radioactive elements which permit repeated and safe use in children. Along with diagnosis, Fees also provides treatment and management recommendations for patients.

Los niños con limitaciones neurológicas son un problema de salud cuya incidencia va en aumento y requiere de un equipo multidisciplinario para su manejo. Frecuentemente presentan trastornos de la deglución (TD) que deben ser sospechados, diagnosticados y manejados por especialistas. En el estudio de los TD existen distintas herramientas que han ido evolucionando en el tiempo. Uno de estos es el estudio endoscópico de la deglución (Fees), que desde su aparición hace 20 años a la actualidad es un examen que ha sido validado para el estudio de la deglución faríngea. La Fees es un estudio estandarizado y sistemático que a través de la visualización directa de las vía aérea superior con un endoscopio flexible nasal, permite la evaluación de la deglución al observar el paso de alimentos. Además del equipo adecuado, requiere un conocimiento acabado de la anatomía pediátrica y entrenamiento por parte del especialista lo que pueden limitar su uso y es fácilmente transportable no utiliza elementos radioactivos lo que permite su uso repetido y seguro en niños. Junto con realizar un diagnóstico la Fees permite entregar las recomendaciones de tratamiento y manejo para el paciente.

Infecciones respiratorias asociadas a traqueostomías en niños / Respiratory infections due to tracheostomy in children

Tracheostomy is the communication between the trachea and the exterior. This procedure is indicated in situations of critical upper airway obstruction or need of long term mechanical ventilation. This condition of airway exposed directly to the environment, without the natural mechanisms of defence, determines a higher risk for infections. This paper seeks defining microbiological situations in patients with tracheostomy and suggests treatment guidelines.

La traqueostomía es un procedimiento que comunica la tráquea con el exterior, indicada en situaciones de obstrucción crítica de la vía aérea alta o necesidad de ventilación mecánica prolongada. Esta situación de comunicación de la vía aérea con el medio, sin los mecanismos de protección naturales, determina un mayor riesgo de infecciones respiratorias. Este artículo busca definir situaciones microbiológicas frecuentes en pacientes con traqueostomía y sugerir líneas de manejo.

Imipenem/cilastatin with or without glycopeptide as initial antibiotic therapy for recipients of autologous stem cell transplantation: results of a Spanish multicenter study.

We analyzed the efficacy of imipenem/cilastatin alone (group I, 197 patients) or in combination with a glycopeptide (group I + G, 231 patients) as first-line antibiotic therapy for 2 consecutive cohorts of autologous stem cell transplantation (ASCT) recipients with febrile neutropenia. From June 2001 to June 2002, patients received imipenem/cilastatin (500 mg/6 hours), and from July 2002 to December 2003, they received imipenem/cilastatin as for group I plus a glycopeptide (vancomycin, 1 g/12 hours or teicoplanin, 400 mg/day). Fever of unknown origin accounted for 33.5% of episodes (66 patients) in group I and 50% of episodes (116 patients) in group I + G (P = .005). Bacteremia occurred in 55 patients (28%) in group I and in 51 patients (22%) in group I + G (P = .16). Resolution of fever without modification of the therapy regimen was observed in 108 patients (55%) and 159 patients (69%) in groups I and I + G, respectively (P = .003). The median interval to defervescence (4 days) and overall mortality were similar between groups. Inclusion of a glycopeptide in the initial antibiotic regimen for febrile neutropenia results in a higher success rate without modifying the regimen. However, glycopeptide inclusion does not improve the interval to defervescence or mortality rate.

Un método sencillo para ayudar a la comprobacióndel correcto posicionamiento de los tubos endotraquealesde doble luz izquierdos / Correct placement of left-sided double lumen endotracheal tubes: a simple verification

OBJETIVO: Los tubos endobronquiales de doble luz (TDL)se utilizan en cirugía torácica para la intubación selectiva pulmonar,necesaria para la ventilación unipulmonar. La comprobaciónde su correcta colocación se realiza mediante fibrobroncoscopia.Presentamos un método simple y alternativopara ayudar a la comprobación del posicionamiento de losTDL izquierdos, que consiste en pasar una sonda de aspiraciónpor la rama traqueal del TDL. Nuestra hipótesis es quesi la sonda pasa sin dificultad el tubo estaría colocado correctamente.El objetivo de este estudio fue la determinación de lasensibilidad y especificidad de la prueba.MATERIAL Y MÉTODO: Pacientes programados para cirugíatorácica electiva de neumonectomía o lobectomíaizquierdas. Tras pasar la sonda por el TDL izquierdo secomprobó con el fibrobroncoscopio (técnica de referencia),comparándose ambos métodos.RESULTADO: Se incluyeron 100 pacientes. De los casosestudiados, en el 88% se dedujo una correcta posición delTDL por paso de sonda sin resistencia. De estos, en el 84%la fibrobroncoscopia corroboró esta situación mientras queen el 4% restante no fue así y hubo que recolocarlos. En el12% se encontró resistencia al pasar la sonda verificándoseen éstos una mala colocación por fibrobroncoscopio.CONCLUSIONES: Si dominamos esta técnica o si no disponemosde fibrobroncoscopio, esta maniobra puede ser útily de mucha ayuda durante la colocación de los TDLizquierdos. Nuestros resultados apoyan la práctica cotidianade esta maniobra, ya que es un método sencillo y accesible,pero recordando que la comprobación mediantefibrobroncoscopio es la técnica de referencia actualmente (AU)

OBJETIVE: Double lumen endotracheal tubes (DLTs)are used in thoracic surgery for selective bronchialintubation, which is required for single lung ventilation.Correct placement of the tube is checked by means offiberoptic bronchoscopy. We present a simple alternativemethod to help confirm the correct placement of left-sidedDLTs. The method consists of passing a suction catheterthrough the tracheal lumen of the tube. Our hypothesiswas that if the catheter can be inserted without difficulty,the tube is correctly placed. The objective was todetermine the sensitivity and specificity of that criterion.MATERIAL AND METHODS: We studied patients scheduledfor elective left pneumonectomy or lobectomy. After passingthe catheter through the left-sided DLT, placement waschecked by means of fiberoptic bronchoscopy (gold standard)and the results were compared with the placementassessment based on ease of insertion.RESULTS: One hundred patients were included. The DLTwas judged to be correctly placed in 88% of patients inwhom the catheter was inserted without resistance.Bronchoscopy corroborated this finding in 84% of cases;the tube was found to be incorrectly placed in theremaining 4% of cases and had to be reinserted. Resistancewas noted in 12% of cases and bronchoscopy confirmedthat the tube was incorrectly placed in those patients.CONCLUSIONS: This technique can be very useful inplacing left-sided DLTs in situations where fiberopticbronchoscopy is not available and if the anesthesiologisthas a thorough command of the method. Our resultssupport the routine use of this criterion as it is simple andeasy to learn. It should be remembered, however, thatconfirmation of placement by means of fiberopticbronchoscopy is currently the gold standard technique (AU)

Veno-occlusive disease of the liver after high-dose cytoreductive therapy with busulfan and melphalan for autologous blood stem cell transplantation in multiple myeloma patients.

Veno-occlusive disease of the liver (VOD) is a potentially severe complication of high-dose cytoreductive therapy (HDT) used for stem cell transplantation (SCT). This complication is uncommon after HDT for autologous SCT (ASCT) in patients with multiple myeloma (MM). The Spanish Myeloma Group/PETHEMA conducted a study (MM2000) for patients with newly diagnosed MM consisting of induction with alternating VBMCP/VBAD chemotherapy followed by intensification with busulfan/melphalan (Bu/MEL) with a second high-dose therapy procedure in patients not achieving at least near-complete remission with the first procedure. After 2 years of the trial, a number of episodes resembling classical VOD but with a late onset were recognized. Consequently, the protocol was modified, and Bu/MEL was replaced by melphalan 200 mg/m(2) (MEL-200). Three years later, after a total of 734 patients had undergone first autologous SCT, the incidence and characteristics of VOD episodes were analyzed in the whole series. Nineteen cases of VOD (8%) were observed among the first 240 patients receiving Bu/MEL, whereas only 2 (0.4%) were observed among the 494 patients treated with MEL-200 (P < .0001). VOD manifestations in the Bu/MEL group appeared at a median of 29 days (range, 3-57 days) after ASCT. Mortality directly attributable to VOD was 2% in the Bu/MEL group and 0.2% in the MEL-200 group (P = .026). This high incidence of severe VOD probably had a multifactorial origin (busulfan followed by melphalan and previous use of BCNU). This observation should be kept in mind when designing future trials for the treatment of MM.