Trombo en tránsito izquierdo intraoperatorio en trasplante bipulmonar diagnosticado por ecocardiografía transesofágica: ¿qué es lo siguiente? / Left side clot in transit in double-lung transplantation diagnosticated by transesophageal echocardiography: What's next?

Un varón de 61 años sin predisposición trombótica es sometido a trasplante bipulmonar como último tratamiento para su EPOC terminal sin soporte de ECMO. Tras el implante y la reperfusión de ambos pulmones, se realizó un examen ecocardiográfico transesofágico completo para comprobar principalmente las anastomosis de las venas pulmonares. En este estudio se identificó una gran masa móvil, hiperecogénica, densa y heterogénea en la aurícula izquierda, compatible con un trombo en tránsito desde la circulación venosa pulmonar. Este hallazgo fue comunicado al equipo quirúrgico inmediatamente para reabrir la anastomosis y retirar el coágulo antes de mayores consecuencias. No hubo manifestaciones clínicas cuando se despertó al paciente.(AU)

61-year-old man without any thrombotic predisposition was undergone double sequential lung transplantation due to terminal stage of COPD without extracorporeal membrane oxygenation (ECMO) support. After implantation and reperfusion of both lungs, a complete transoesophageal echocardiography exam was performed to check especially the pulmonary venous anastomosis. In this exam, a large heterogenous, dense, hyperechoic mobile mass was identified in the LA, which was compatible with a thrombus in transit from pulmonary veins circulation. This finding was communicated to the surgical team to reopen the anastomosis and remove the clot before further consequences. There were no clinical manifestations when the patient was awakened.(AU)

Left side clot in transit in double-lung transplantation diagnosticated by transesophageal echocardiography: what's next?

A 61-year-old man with no predisposition to thrombosis underwent sequential double lung transplantation without extracorporeal membrane oxygenation (ECMO) support due to terminal stage COPD. After implantation and reperfusion of both lungs, a complete transoesophageal echocardiography study was performed to check the pulmonary venous anastomosis. The study showed a large, heterogeneous, dense, hyperechoic free-floating mass in the left atrium compatible with a clot in transit from the pulmonary circulation. The surgical team were notified of this finding so that they could reopen the anastomosis and remove the clot to prevent a major complication. There were no clinical manifestations when the patient was awakened.

Actualización sobre el uso de la ecografía en el diagnóstico y monitorización del paciente crítico / Update on the use of ultrasound in the diagnosis and monitoring of the critical patient

Las complicaciones cardiorrespiratorias son las principales causas de morbimortalidad en las unidades de cuidados críticos (UCC). Las técnicas de imagen son una pieza fundamental tanto en el diagnóstico diferencial como en el tratamiento. En la última década la ecografía ha demostrado gran potencial para el diagnóstico a pie de cama de patología respiratoria, así como para la valoración hemodinámica de los pacientes críticos. La ecografía ha demostrado ser una guía útil para la identificación del tipo de shock, la estimación del gasto cardiaco, guiar la fluidoterapia y los fármacos vasoactivos, aportar seguridad en la realización de las técnicas percutáneas (toracocentesis, pericardiocentesis, evacuación de abscesos/hematomas), objetivar de forma dinámica y en tiempo real la atelectasia pulmonar y su respuesta a las maniobras de reclutamiento alveolar, y predecir el fracaso en el destete de la ventilación mecánica. Por su carácter dinámico, sencilla curva de aprendizaje y ausencia de radiación ionizante, se ha incorporado como una herramienta imprescindible en la práctica clínica diaria en las UCC. El objetivo de la presente revisión es ofrecer una visión global del papel de la ecografía y sus aplicaciones en el paciente crítico.(AU)

Hemodynamic and respiratory complications are the main causes of morbidity and mortality in in critical care units (CCU). Imaging techniques are a key tool in differential diagnosis and treatment. In the last decade, ultrasound has shown great potential for bedside diagnosis of respiratory disease, as well as for the hemodynamic assessment of critically ill patients. Ultrasound has proven to be a useful guide for identifying the type of shock, estimating cardiac output, guiding fluid therapy and vasoactive drugs, providing security in the performance of percutaneous techniques (thoracentesis, pericardiocentesis, evacuation of abscesses/hematomas), detecting dynamically in real time pulmonary atelectasis and its response to alveolar recruitment maneuvers, and predicting weaning failure from mechanical ventilation. Due to its dynamic nature, simple learning curve and absence of ionizing radiation, it has been incorporated as an essential tool in daily clinical practice in CCUs. The objective of this review is to offer a global vision of the role of ultrasound and its applications in the critically ill patient.(AU)

Update on the use of ultrasound in the diagnosis and monitoring of the critical patient.

Hemodynamic and respiratory complications are the main causes of morbidity and mortality in in critical care units (CCU). Imaging techniques are a key tool in differential diagnosis and treatment. In the last decade, ultrasound has shown great potential for bedside diagnosis of respiratory disease, as well as for the hemodynamic assessment of critically ill patients. Ultrasound has proven to be a useful guide for identifying the type of shock, estimating cardiac output, guiding fluid therapy and vasoactive drugs, providing security in the performance of percutaneous techniques (thoracentesis, pericardiocentesis, evacuation of abscesses/hematomas), detecting dynamically in real time pulmonary atelectasis and its response to alveolar recruitment maneuvers, and predicting weaning failure from mechanical ventilation. Due to its dynamic nature, simple learning curve and absence of ionizing radiation, it has been incorporated as an essential tool in daily clinical practice in CCUs. The objective of this review is to offer a global vision of the role of ultrasound and its applications in the critically ill patient.

Consensus on the Definition of Control and Remission in Chronic Urticaria.

The terms control and remission and other key terms used in chronic urticaria (CU) such as flare-up, relapse, exacerbation, and recurrence have not been fully defined in the literature. Disease monitoring and treatment goals in clinical practice are not well established. After a qualitative appraisal of available evidence, we aimed to find a consensus definition of control and remission, clarify key terminology, provide guidance on how to monitor the disease, and establish treatment goals in clinical practice. A modified Delphi consensus approach was used. Based on a literature review, a scientific committee provided 137 statements addressing controversial definitions and terms, available patient-reported outcomes (PROs), and recommendations on how to measure therapeutic objectives in CU. The questionnaire was evaluated by 138 expert allergists and dermatologists. A consensus was reached on 105 out of the 137 proposed items (76.6%). The experts agreed that complete control and remission of CU could be defined as the absence of signs or symptoms while on treatment and in the absence of treatment, respectively. Consensus was not reached on the definition of other key terms such as flare-up, exacerbation, and recurrence. The panel agreed that the objective of therapy in CU should be to achieve complete control. PROs that define the degree of control (complete, good, partial, or absence) were established. An algorithm for disease assessment is provided. In conclusion, this work offers consensus definitions and tools that may be useful in the management of patients with CU.

A Specialized Therapeutic Approach to Chronic Urticaria Refractory to H1-Antihistamines Improves Disease Burden: The Spanish AWARE Experience.

OBJECTIVE: During its first year, the AWARE study assessed disease activity, patient quality of life (QOL), and treatment patterns in chronic urticaria (CU) refractory to H1-antihistamines (H1-AH) in clinical practice. METHODS: We performed an observational, prospective (24 months), international, multicenter study. The inclusion criteria were age ≥18 years and H1-AH-refractory CU (>2 months). At each visit, patients completed questionnaires to assess disease burden (Urticaria Control Test [UCT]), disease activity (7 day-Urticaria Activity Score [UAS7]), and QOL (Dermatology Life Quality index [DLQI], Chronic Urticaria Quality of Life Questionnaire [CU-Q2oL], and Angioedema Quality of Life Questionnaire [AE-QoL]). We present data for Spain. RESULTS: The study population comprised 270 evaluable patients (73.3% female, mean [SD] age, 48.9 [14.7] years). At baseline, 89.3% were prescribed a CU treatment. After 1 year, first- and second-line treatments became less frequent and third-line treatments became more frequent. At baseline, 47.0% of patients experienced angioedema; at 1 year, this percentage had fallen to 11.8%. The mean (SD) AE-QoL score decreased from 45.2 (28.7) to 24.0 (25.8). The mean (SD) UCT score decreased from 7.0 (4.5) to 12.1 (4.1). According to UAS7, 38.2% of patients reported absence of wheals and itch in the previous 7 days at 1 year compared with 8.3% at baseline. The mean (SD) DLQI score decreased from 8.0 (7.4) to 2.8 (4.6). At the 1-year visit, the percentage of patients reporting a high or very high impact on QOL fell from 29.9% to 9.6%. CONCLUSION: H1-AH-refractory CU in Spain is characterized by absence of control of symptoms and a considerable impact on QOL. Continuous follow-up of CU patients and third-line therapies reduce disease burden and improve patients' QOL.

A Specialized Therapeutic Approach to Chronic Urticaria Refractory to H1-Antihistamines Improves Disease Burden: The Spanish AWARE Experience

Objective: During its first year, the AWARE study assessed disease activity, patient quality of life (QOL), and treatment patterns in chronic urticaria (CU) refractory to H1-antihistamines (H1-AH) in clinical practice.Methods: We performed an observational, prospective (24 months), international, multicenter study. The inclusion criteria were age ≥18 years and H1-AH–refractory CU (>2 months). At each visit, patients completed questionnaires to assess disease burden (Urticaria Control Test [UCT]), disease activity (7 day-Urticaria Activity Score [UAS7]), and QOL (Dermatology Life Quality index [DLQI], Chronic Urticaria Quality of Life Questionnaire [CU-Q2oL], and Angioedema Quality of Life Questionnaire [AE-QoL]). We present data for Spain.Results: The study population comprised 270 evaluable patients (73.3% female, mean [SD] age, 48.9 [14.7] years). At baseline, 89.3% were prescribed a CU treatment. After 1 year, first- and second-line treatments became less frequent and third-line treatments became more frequent. At baseline, 47.0% of patients experienced angioedema; at 1 year, this percentage had fallen to 11.8%. The mean (SD) AE-QoL score decreased from 45.2 (28.7) to 24.0 (25.8). The mean (SD) UCT score decreased from 7.0 (4.5) to 12.1 (4.1). According to UAS7, 38.2% of patients reported absence of wheals and itch in the previous 7 days at 1 year compared with 8.3% at baseline. The mean (SD) DLQI score decreased from 8.0 (7.4) to 2.8 (4.6). At the 1-year visit, the percentage of patients reporting a high or very high impact on QOL fell from 29.9% to 9.6%.Conclusions: H1-AH–refractory CU in Spain is characterized by absence of symptoms and a considerable impact on QOL. Continuous follow-up of CU patients and third-line therapies reduce disease burden and improve patients’ QOL (AU)

Objetivo: El estudio AWARE evalúa la actividad de la enfermedad, la calidad de vida (CV) del paciente y los patrones de tratamientoen pacientes con urticaria crónica (UC) refractarios a antihistamínicos H1 (AH-H1) en práctica clínica durante el primer año del estudio.Métodos: Estudio observacional, prospectivo (24 meses), internacional y multicéntrico. Pacientes ≥18 años con diagnóstico de UC refractariosa AH-H1 (>2 meses). En cada visita, los pacientes completaron cuestionarios para evaluar la carga de la enfermedad (Urticaria Control Test[UCT]), actividad de la enfermedad (7 day-Urticaria Activity Score [UAS7]), CV (Dermatology Life Quality index [DLQI], Chronic UrticariaQuality of Life Questionnaire [CU-Q2oL], Angioedema Quality of Life [AE-QOL]). Presentamos datos españoles.Resultados: Se incluyeron 270 pacientes evaluables (73,3% mujeres, edad media [DE] 48,9 [14,7] años). Al inicio del estudio, al 89,3%se le prescribió un tratamiento para la UC. Después de 1 año, los tratamientos de primera/segunda línea tendieron a disminuir y la tercera línea a aumentar. El 47,0% de los pacientes experimentaron angioedema al inicio del estudio, siendo del 11,8% al cabo de 1 año. Lamedia (DE) de AE-QOL pasó de 45,2 (28,7) a 24,0 (25,8). La media (DE) de UCT pasó de 7,0 (4,5) a 12,1 (4,1). Según UAS7, el 38,2% depacientes reportaron ausencia de ronchas y prurito en los últimos 7 días al año frente al 8,3% al inicio. El DLQI medio (DE) pasó de 8,0 (7,4)a 2,8 (4,6). En la visita de 1 año, el porcentaje de pacientes que reportaron un impacto en la CV alto/muy alto pasó del 29,9% al 9,6%.Conclusiones: Los pacientes españoles con UC refractarios a AH-H1 presentan una falta de control de la sintomatología con un importanteimpacto en su CV. El seguimiento continuo de los pacientes con urticaria crónica espontánea y las terapias de tercera línea han demostradouna tendencia a reducir la carga de la enfermedad y a mejorar la CV de los pacientes (AU)

Consensus on the Definition of Control and Remission in Chronic Urticaria

The terms control and remission and other key terms used in chronic urticaria (CU) such as flare-up, relapse, exacerbation, and recurrence have not been fully defined in the literature. Disease monitoring and treatment goals in clinical practice are not well established. After a qualitative appraisal of available evidence, we aimed to find a consensus definition of control and remission, clarify key terminology, provide guidance on how to monitor the disease, and establish treatment goals in clinical practice. A modified Delphi consensus approach was used. Based on a literature review, a scientific committee provided 137 statements addressing controversial definitions and terms, available patient-reported outcomes (PROs), and recommendations on how to measure therapeutic objectives in CU. The questionnaire was evaluated by 138 expert allergists and dermatologists. A consensus was reached on 105 out of the 137 proposed items (76.6%). The experts agreed that complete control and remission of CU could be defined as the absence of signs or symptoms while on treatment and in the absence of treatment, respectively. Consensus was not reached on the definition of other key terms such as flare-up, exacerbation, and recurrence. The panel agreed that the objective of therapy in CU should be to achieve complete control. PROs that define the degree of control (complete, good, partial, or absence) were established. An algorithm for disease assessment is provided. In conclusion, this work offers consensus definitions and tools that may be useful in the management of patients with CU (AU)

El concepto de control y remisión de la enfermedad, así como otros términos clave utilizados en la urticaria crónica (UC), como reagudización, recaída, exacerbación o recurrencia, no están totalmente aclarados en la literatura. Tampoco está bien establecido el seguimiento de la enfermedad y los objetivos del tratamiento en la práctica clínica. Tras una evaluación cualitativa de la evidencia, nos propusimos encontrar una definición consensuada de control y remisión de la UC, aclarar terminología clave, proporcionar orientación sobre cómo monitorizar la enfermedad y establecer objetivos de tratamiento en la práctica clínica. Para llegar a un consenso, se utilizó una técnica Delphi modificada. Basándose en una revisión de la literatura, un comité científico elaboró 137 aseveraciones que abordaban definiciones y términos controvertidos, el uso de Patient Reported Outcomes (PROs) y recomendaciones sobre cómo medir los objetivos terapéuticos en la UC. El cuestionario fue evaluado por 138 alergólogos y dermatólogos expertos. Se alcanzó un consenso en 105 de las 137 aseveraciones propuestas (76,6%). Los expertos estuvieron de acuerdo en que el control completo y la remisión de la CU podrían definirse como la ausencia de signos o síntomas de la enfermedad mientras se está en tratamiento y en ausencia de tratamiento, respectivamente. No se alcanzó un consenso sobre la definición de otros términos clave como reagudización, exacerbación o recurrencia. El panel estuvo de acuerdo en que el objetivo terapéutico de la CU debe ser lograr un control completo. Se establecieron los PROs que definen el grado de control de la CU (completo, bueno, parcial o ausencia de control). Además, se creó un algoritmo para la evaluación de la enfermedad. En conclusión, este trabajo ofrece definiciones y herramientas de consenso que pueden ser útiles en el manejo de los pacientes con CU (AU)

Anaphylaxis Due to Senna (Cassia angustifolia)

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Encuesta multicéntrica sobre el empleo de la ecocardiografía intraoperatoria en cirugía cardiovascular en España. Artículo breve / Multicentric survey on the use of intraoperative echocardiography in cardiovascular surgery in Spain

La ecocardiografía transesofágica (ETE) es una herramienta fundamental en el intraoperatorio y postoperatorio de cirugía cardiaca con una gran difusión en los últimos años. El objetivo de este trabajo es conocer la situación actual de la ETE en el ámbito de la anestesiología en cirugía cardiaca en España a través de una encuesta nacional que explora la disponibilidad de equipos, indicación y utilización de dicha técnica, así como la formación y acreditación de los profesionales responsables. Los hallazgos muestran que en España la ETE intraoperatoria es parte integral de los procedimientos cardiovasculares hoy en día y en la mayor parte de los centros es realizada por anestesiólogos altamente involucrados en este tipo de cirugías. A pesar de la ausencia de formación estructurada en el currículum formativo de nuestra especialidad, los anestesiólogos adquieren las competencias mediante rotaciones específicas de corta duración y un alto porcentaje de ellos ha obtenido la acreditación oficial

Transesophageal echocardiography (TEE) is an essential tool in the intraoperative and postoperative period of cardiac surgery with recently wide diffusion. We aimed to know the current situation of TEE in the field of cardiovascular anesthesiology in Spain through a national survey that explores the availability of equipment, indication and use of this technique as well as the training and accreditation of professionals involved. The findings show that in Spain intraoperative TEE is an integral part of cardiovascular procedures today and in most centers it is performed by anesthesiologists highly involved in this type of surgery. Despite the absence of structured training in the curriculum of our specialty, anesthesiologists acquire the skills through specific short-term rotations and a high percentage of them have obtained official accreditation

Multicentric survey on the use of intraoperative echocardiography in cardiovascular surgery in Spain. / Encuesta multicéntrica sobre el empleo de la ecocardiografía intraoperatoria en cirugía cardiovascular en España. Artículo breve.

Transesophageal echocardiography (TEE) is an essential tool in the intraoperative and postoperative period of cardiac surgery with recently wide diffusion. We aimed to know the current situation of TEE in the field of cardiovascular anesthesiology in Spain through a national survey that explores the availability of equipment, indication and use of this technique as well as the training and accreditation of professionals involved. The findings show that in Spain intraoperative TEE is an integral part of cardiovascular procedures today and in most centers it is performed by anesthesiologists highly involved in this type of surgery. Despite the absence of structured training in the curriculum of our specialty, anesthesiologists acquire the skills through specific short-term rotations and a high percentage of them have obtained official accreditation.

Tolerance to cephalosporins and carbapenems in penicillin-allergic patients

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Changing perspectives in atopic dermatitis

Atopic dermatitis (AD) is a multifaceted disease that involves a complex interplay between the skin and the immune system. The course of the disease depends strongly on the genetic background of the patient and on yet poorly-defined environmental factors. Changes in lifestyle could be behind the dramatic rise in the prevalence of AD across continents; including hygienic conditions, food, social habits, skin microbiome or exposure to a number of allergens. Although AD typically develops in childhood and disappears after a few years, in a relatively large number of patients it continues into adulthood. Adult AD can also appear de novo but it is often underdiagnosed and its treatment can be challenging. New, highly effective drugs are being developed to manage moderate and severe forms of the disease in adults. In this review, we highlight the most recent developments in diagnostic tools, current insights into the mechanistic basis of this disease, and therapeutic innovations

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Changing perspectives in atopic dermatitis.

Atopic dermatitis (AD) is a multifaceted disease that involves a complex interplay between the skin and the immune system. The course of the disease depends strongly on the genetic background of the patient and on yet poorly-defined environmental factors. Changes in lifestyle could be behind the dramatic rise in the prevalence of AD across continents; including hygienic conditions, food, social habits, skin microbiome or exposure to a number of allergens. Although AD typically develops in childhood and disappears after a few years, in a relatively large number of patients it continues into adulthood. Adult AD can also appear de novo but it is often underdiagnosed and its treatment can be challenging. New, highly effective drugs are being developed to manage moderate and severe forms of the disease in adults. In this review, we highlight the most recent developments in diagnostic tools, current insights into the mechanistic basis of this disease, and therapeutic innovations.

Allergy rhinitis: similarities and differences between children and adults.

BACKGROUND: Allergic rhinitis (AR) is a highly prevalent disease worldwide. Although a number of studies have described AR, no studies compared children and adult AR populations. The objective was to compare the AR characteristics between two AR cohorts of children and adults. METHODS: Two AR cohorts (children and adults) from Spain were studied through observational cross-sectional multicentre studies. AR was classified based on classical (allergen exposure), original (o-ARIA), and modified (m-ARIA) ARIA criteria. AR was evaluated by Total 4-Symptoms Score (T4SS), and disease severity by Visual Analogue Scale (VAS, 0-100 mm). AR comorbidities were also evaluated. RESULTS: A total of 5,405 patients (1,275 children, 4,130 adults) were studied. According to symptoms duration, intermittent AR was more frequent in children than in adults. Using o-ARIA severity, more children than adults had moderate/severe AR while, using m-ARIA, more children than adults had severe AR. T4SS was higher in adults than in children. Moreover, VAS was also higher in adults than in children. In addition, asthma atopic dermatitis and conjunctivitis were more associated to children than adults with AR, the frequency of this comorbidities increasing according to higher severity. CONCLUSIONS: AR in children was more intermittent, severe, with less symptoms but with more comorbidities than in adults. These results suggest AR has similarities but also significant differences between children and adults.

Management of chronic spontaneous urticaria in routine clinical practice: a Delphi-method questionnaire among specialists to test agreement with current European guidelines statements

BACKGROUND: Chronic spontaneous urticaria (CSU) is a frequent clinical entity that often presents a diagnostic and therapeutic challenge. OBJECTIVE: To explore the degree of agreement that exists among the experts caring for patients with CSU diagnosis, evaluation, and management. METHODS: An online survey was conducted to explore the opinions of experts in CSU, address controversial issues, and provide recommendations regarding its definition, natural history, diagnosis, and treatment. A modified Delphi method was used for the consensus. RESULTS: The questionnaire was answered by 68 experts (dermatologists, allergologists, and primary care physicians). A consensus was reached on 54 of the 65 items posed (96.4%). The experts concluded that CSU is a difficult-to-control disease of unpredictable evolution. Diagnostic tests should be limited and based on clinical history and should not be indiscriminate. Autoinflammatory syndromes and urticarial vasculitis must be ruled out in the differential diagnosis. A cutaneous biopsy is only recommended when wheals last more than 24h, to rule out urticarial vasculitis. The use of specific scales to assess the severity of the disease and the quality of life is recommended. In patients with severe and resistant CSU, second-generation H1-antihistamines could be used at doses up to four times the standard dose before giving second-line treatments. Omalizumab is a safe and effective treatment for CSU that is refractory to H1-antihistamines treatment. In general, diagnosis and treatment recommendations given for adults could be extrapolated to children. CONCLUSIONS: This work offers consensus recommendations that may be useful in the management of CSU

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