Response to editorial: Gastric and pancreatic cancer trends in Spain.

This response to an editorial discusses recent trends in gastric and pancreatic cancer mortality in Spain. The authors acknowledge the contrasting trajectories - a decrease in gastric cancer and an increase in pancreatic cancer - and attribute them to differing causes. Public health measures, particularly H. pylori eradication, are credited for the decline in gastric cancer. The authors also present unpublished data showing a worrying rise in gastric cancer diagnoses among young men. They emphasize the need for continued monitoring, early detection strategies, and preventative measures to tackle both cancers, particularly focusing on pancreatic cancer research due to its rising mortality.

Investigating temporal patterns of colorectal cancer incidence in Spain: a comprehensive analysis of age, period and cohort effects, 1990-2019.

AIM: This study aimed to evaluate how age, period, and cohort (A-P-C) impact colorectal cancer (CRC) incidence in Spain from 1990 to 2019. METHOD: Using data from the Global Burden of Disease Study 2019, we used joinpoint analysis to identify long-term trends and A-P-C modelling to quantify net drift, local drift, longitudinal age curves, and rate ratios (RRs) of period and cohort effects. RESULTS: CRC incidence increased steadily in Spain from 1990 to 2019, with a more significant rise in men than in women. The age standardised rates rose from 84.9 to 129.3 cases per 100,000 in men and from 56.9 to 70.3 cases per 100,000 in women. Joinpoint analysis revealed distinct patterns for men and women: men's incidence showed three phases--a surge until 1995, a slowdown until 2012, and a subsequent decrease--while women's incidence experienced a single increase until 2011 and then stabilized. Local drifts increased in all age groups over 45, with stability in men under 45 and a decrease in women aged 30-39. The risk of CRC increased with age, with men consistently having a higher risk than women. The risk of CRC increased over time for both men and women but at different rates. The risk for cohorts born in the early to mid-20th century peaked in the 1960s and remained stable until the late 1990s. CONCLUSION: The increasing incidence of CRC in Spain, with distinct patterns by gender and birth cohort, underlines the importance of preventive strategies adapted to temporal and demographic variations to address this public health challenge.

Has the trend in pancreatic cancer mortality in Spain started to slow down?

INTRODUCTION: the aim of this study was to describe the trends of pancreatic cancer mortality by autonomous communities (ACs) and gender in Spain (1980-2021). METHODS: an ecological trend study was performed (with aggregated data obtained from the National Institute of Statistics). Age-standardized mortality rates (ASMRs) for pancreatic cancer (per 100,000) were estimated by direct standardization, using the European standard population. Trends in ASMR (all ages and truncated 35-64 years) were analyzed by sex in each AC using a joinpoint regression model. The annual percent changes (APC) and average annual percentage of change (AAPC) were computed for trends using the joinpoint regression analysis. RESULTS: in both sexes, ASMRs (all ages) increased significantly (p < 0.05) during the study period (AAPC: 1.5 % in males and 1.8 % in females). The joinpoint analysis identified a turning point in the trends in the late 1980s, which delineates two periods: an initial period of significant increase followed by a period of slowing of the increase (APC: 0.9 % and 1.4 % in males and females respectively; p < 0.05). In both sexes, a significant increase in ASMR (all ages) was observed in all ACs, except in Navarre, where the rates remained stable in males. In males, three ACs (Galicia, Madrid and Navarre) showed a point of inflexion in the time trend around the year 2000 (1999, 2000 and 2001 respectively), when the rates, after a period of significant increase (ACs: 2.6 %, 2.4 %, and 2.4 %, respectively; p < 0.05), stabilized (Galicia and Navarre) or the increase slowed (Madrid). In females, only Madrid showed a point of inflection in 1992, when, after a significant increase, the rates slowed down (1992-2021; APC: 1.5 %; p < 0.05). Conclusions: the upward trend in pancreatic cancer mortality in some ACs seems to have slowed (in both sexes in Madrid), stabilized (in men in Galicia and Navarre) or turned around (in men aged 30-64 in Navarre).

Has the trend in pancreatic cancer mortality in Spain started to slow down?

Introduction: the aim of this study was to describe the trends of pancreatic cancer mortality by autonomous communities (ACs) and gender in Spain (1980-2021). Methods: an ecological trend study was performed (with aggregated data obtained from the National Institute of Statistics). Age-standardized mortality rates (ASMRs) for pancreatic cancer (per 100,000) were estimated by direct standardization, using the European standard population. Trends in ASMR (all ages and truncated 35-64 years) were analyzed by sex in each AC using a joinpoint regression model. The annual percent changes (APC) and average annual percentage of change (AAPC) were computed for trends using the joinpoint regression analysis. Results: in both sexes, ASMRs (all ages) increased significantly (p < 0.05) during the study period (AAPC: 1.5 % in males and 1.8 % in females). The joinpoint analysis identified a turning point in the trends in the late 1980s, which delineates two periods: an initial period of significant increase followed by a period of slowing of the increase (APC: 0.9 % and 1.4 % in males and females respectively; p < 0.05). In both sexes, a significant increase in ASMR (all ages) was observed in all ACs, except in Navarre, where the rates remained stable in males. In males, three ACs (Galicia, Madrid and Navarre) showed a point of inflexion in the time trend around the year 2000 (1999, 2000 and 2001 respectively), when the rates, after a period of significant increase (ACs: 2.6 %, 2.4 %, and 2.4 %, respectively; p < 0.05), stabilized (Galicia and Navarre) or the increase slowed (Madrid). In females, only Madrid showed a point of inflection in 1992, when, after a significant increase, the rates slowed down (1992-2021; APC: 1.5 %; p < 0.05).  Conclusions: the upward trend in pancreatic cancer mortality in some ACs seems to have slowed (in both sexes in Madrid), stabilized (in men in Galicia and Navarre) or turned around (in men aged 30-64 in Navarre) (AU)

Development, Implementation, and Evaluation of a Telemedicine Service for the Treatment of Acute Stroke Patients: TeleStroke.

BACKGROUND: Health care service based on telemedicine can reduce both physical and time barriers in stroke treatments. Moreover, this service connects centers specializing in stroke treatment with other centers and practitioners, thereby increasing accessibility to neurological specialist care and fibrinolytic treatment. OBJECTIVE: Development, implementation, and evaluation of a care service for the treatment of acute stroke patients based on telemedicine (TeleStroke) at Virgen del Rocío University Hospital. METHODS: The evaluation phase, conducted from October 2008 to January 2011, involved patients who presented acute stroke symptoms confirmed by the emergency physician; they were examined using TeleStroke in two hospitals, at a distance of 16 and 110 kilometers from Virgen del Rocío University Hospital. We analyzed the number of interconsultation sheets, the percentage of patients treated with fibrinolysis, and the number of times they were treated. To evaluate medical professionals' acceptance of the TeleStroke system, we developed a web-based questionnaire using a Technology Acceptance Model. RESULTS: A total of 28 patients were evaluated through the interconsultation sheet. Out of 28 patients, 19 (68%) received fibrinolytic treatment. The most common reasons for not treating with fibrinolysis included: clinical criteria in six out of nine patients (66%) and beyond the time window in three out of nine patients (33%). The mean "onset-to-hospital" time was 69 minutes, the mean time from admission to CT image was 33 minutes, the mean "door-to-needle" time was 82 minutes, and the mean "onset-to-needle" time was 150 minutes. Out of 61 medical professionals, 34 (56%) completed a questionnaire to evaluate the acceptability of the TeleStroke system. The mean values for each item were over 6.50, indicating that respondents positively evaluated each item. This survey was assessed using the Cronbach alpha test to determine the reliability of the questionnaire and the results obtained, giving a value of 0.97. CONCLUSIONS: The implementation of TeleStroke has made it possible for patients in the acute phase of stroke to receive effective treatment, something that was previously impossible because of the time required to transfer them to referral hospitals.

[Factors that affect time delays to fibrinolytic treatment in ischaemic stroke]. / Factores que influyen en la demora del tratamiento fibrinolitico en el ictus isquémico.

INTRODUCTION: Extending the thrombolytic therapy window in ischaemic stroke to 4.5 hours has proved to be useful and safe, but a prompt response remains a decisive factor. AIM: To analyse the factors that delay treatment. PATIENTS AND METHODS: After activating the Stroke Code procedure, the consecutive cases of stroke attended in the emergency department throughout the year 2006 were recorded; data included their clinical and epidemiological features, origin, means of transport and delay times in the process. RESULTS: Of the total number of patients with ischaemic stroke, 10.1% finished the emergency study with a median of 1 hour to decide to carry out treatment within 3 hours, and 13.1% of them between 3 and 4.5 hours, with a median of 2 hours and 6 minutes. For the analysis of all the variables, 498 patients were selected; 39% were admitted to hospital within the first 3 hours and 11.2% between 3 and 4.5 hours of the onset of symptoms. The use of the emergency telephone system, transport by mobile ICU or ambulance and an impaired level of consciousness, sight or, to a lesser extent, language or speech were related to shorter delay times. CONCLUSIONS: The factors that depended on the actual patient, in general, did not shorten the delay time. Clinical severity, the presence of informants and activating the emergency system shortened intervention times.

Factores que influyen en la demora del tratamiento fibrinolítico en el ictus isquémico / Factors that affect time delays to fibrinolytic treatment in ischaemic stroke

Introducción. Ampliar la ventana terapéutica trombolítica del ictus isquémico hasta las 4,5 horas se ha demostrado útil y seguro, pero la celeridad en la respuesta sigue siendo determinante. Objetivo. Analizar los factores que demoran el tratamiento. Pacientes y métodos. Tras activar el dispositivo Código Ictus, se registraron los casos consecutivos de ictus atendidos en urgencias durante el año 2006, sus características clínicas, epidemiológicas, procedencia, modo de traslado y demoras del proceso. Resultados. Del total de pacientes con ictus isquémico, el 10,1% concluyó el estudio de urgencias con una mediana de 1 hora para decidir tratar en las 3 horas y el 13,1%, entre las 3 y 4,5 horas con una mediana de 2 horas y 6 minutos. Para el análisis de todas las variables se seleccionó a 498 pacientes; el 39% ingresó en las primeras 3 horas y el 11,2% entre las 3 y 4,5 horas del inicio de los síntomas. El uso del sistema telefónico de emergencias, el traslado en UCI móvil o ambulancia y el déficit en el nivel de conciencia, visual o, en menor grado, del lenguaje o habla incidieron en una demora menor. Conclusiones. Los factores dependientes del propio paciente, en general, no disminuyeron la demora. La gravedad clínica, la presencia de informadores y la activación del sistema de emergencias acortaron los tiempos en las actuaciones (AU)

Introduction. Extending the thrombolytic therapy window in ischaemic stroke to 4.5 hours has proved to be useful and safe, but a prompt response remains a decisive factor. Aim. To analyse the factors that delay treatment. Patients and methods. After activating the Stroke Code procedure, the consecutive cases of stroke attended in the emergency department throughout the year 2006 were recorded; data included their clinical and epidemiological features, origin, means of transport and delay times in the process. Results. Of the total number of patients with ischaemic stroke, 10.1% finished the emergency study with a median of 1 hour to decide to carry out treatment within 3 hours, and 13.1% of them between 3 and 4.5 hours, with a median of 2 hours and 6 minutes. For the analysis of all the variables, 498 patients were selected; 39% were admitted to hospital within the first 3 hours and 11.2% between 3 and 4.5 hours of the onset of symptoms. The use of the emergency telephone system, transport by mobile ICU or ambulance and an impaired level of consciousness, sight or, to a lesser extent, language or speech were related to shorter delay times. Conclusions. The factors that depended on the actual patient, in general, did not shorten the delay time. Clinical severity, the presence of informants and activating the emergency system shortened intervention times (AU)

[False diagnoses of strokes in emergency departments]. / Falsos diagnósticos de ictus en los servicios de urgencias.

INTRODUCTION: Diagnosing a stroke can sometimes be difficult. There are a number of mimic conditions that can lead to false diagnoses. AIM: To examine false diagnoses of acute stroke. PATIENTS AND METHODS: We reviewed the medical histories with diagnoses of acute stroke -i.e. ischaemic or haemorrhagic stroke and transient ischaemic attack (TIA)- for a three-month period. Alternative diagnoses were established in doubtful stroke cases (without meeting the World Health Organisation stroke criteria). RESULTS: Altogether there were 358 patients: 110 TIA, 191 ischaemics and 57 haemorrhagics. In all, 65 false diagnoses were selected, which represented 18.2% of the total number (41.8% of the cases of TIA) and 31.8% of the strokes admitted in the emergency department. The subtypes of false diagnoses were: 46 TIA (70.8%), 18 ischaemics (27.7%) and one haemorrhagic (1.5%). The alternative diagnoses were the following: syncope/pre-syncope in 10.8% of cases (n = 7); confusional syndrome/disorientation in 21.5% (n = 14); lowered level of consciousness in 27.7% (n = 18); generalised weakness in 6.2% (n = 4); dizziness/vertigo in 3.1% (n = 2); isolated dysarthria in 10.8% (n = 7); epileptic seizure in 6.2% (n = 4); and others in 13.8% (n = 9). A total of 71.7% could be attributed to systemic causes. The mean age was 79 years and 64.6% were females (n = 42). Computerised tomography of the head was performed in 70.8% of the cases (n = 46). A neurologist assessed 7.7% of them (n = 5). The destination on being discharged was: primary care (53.3%), visit to neurology department (31.7%), visit internal medicine department (6.7%), hospitalisation in neurology department (1.7%), hospitalisation in other specialties (1.7%), transfer (1.7%) and death (3.3%). CONCLUSIONS: False diagnoses of cerebrovascular diseases are common. In emergency departments almost half of the diagnoses of TIA may be wrong. Most false diagnoses refer to TIA (70%) and occur in elderly patients, can be attributed to systemic causes, have not been assessed by a neurologist and are referred to primary care. Hospital stroke registries that include emergency patients may be overestimated, especially in the number of cases of TIA.

Falsos diagnósticos de ictus en los servicios de urgencias / False diagnoses of strokes in emergency departments

Introducción. El diagnóstico de ictus en ocasiones puede ser difícil. Existen numerosas condiciones simuladoras que pueden dar lugar a falsos diagnósticos. Objetivo. Estudiar falsos diagnósticos de ictus agudo. Pacientes y métodos. Revisamos las historias con diagnóstico de ictus agudo –isquémico, hemorrágico y accidente isquémico transitorio (AIT)– durante tres meses. Ante ictus dudosos (sin criterios de ictus según la Organización Mundial de la Salud) se establecieron diagnósticos alternativos. Resultados. El total fue de 358 pacientes: 110 AIT, 191 isquémicos y 57 hemorrágicos. Se seleccionaron 65 falsos diagnósticos, correspondientes al 18,2% del total (el 41,8% de los AIT) y al 31,8% de los ictus de alta en urgencias (el 46,4% de los AIT). Los subtipos de falsos diagnósticos fueron: 46 AIT (70,8%), 18 isquémicos (27,7%) y uno hemorrágico (1,5%). Los diagnósticos alternativos fueron: síncope/presíncope en el 10,8% de los casos (n = 7); síndrome confusional/desorientación en el 21,5% (n = 14); disminución del nivel de conciencia en el 27,7% (n = 18); debilidad generalizada en el 6,2% (n = 4); mareo/ vértigo en el 3,1% (n = 2); disartria aislada en el 10,8% (n = 7); crisis epiléptica en el 6,2% (n = 4); y otros en el 13,8% (n = 9). Fue atribuible a causas sistémicas el 71,7%. La edad media fue de 79 años y el 64,6% eran mujeres (n = 42). Se realizó tomografía computarizada craneal al 70,8% (n = 46). El 7,7% fue valorado por el neurólogo (n = 5). El destino en el momento del alta fue: atención primaria (53,3%), consultas de neurología (31,7%), consultas de medicina interna (6,7%), hospitalización en neurología (1,7%), hospitalización en otras especialidades (1,7%), traslado (1,7%) y fallecimiento (3,3%). Conclusiones. Los falsos diagnósticos de enfermedades cerebrovasculares son frecuentes. En los servicios de urgencias casi la mitad de diagnósticos de AIT pueden ser erróneos. La mayoría de los falsos diagnósticos corresponden a AIT (70%), son pacientes ancianos, atribuibles a causas sistémicas, no valorados por neurología y remitidos a atención primaria. Los registros hospitalarios de ictus que incluyen pacientes de urgencias pueden estar sobreestimados, principalmente los AIT (AU)

Introduction. Diagnosing a stroke can sometimes be difficult. There are a number of mimic conditions that can lead to false diagnoses. Aim. To examine false diagnoses of acute stroke. Patients and methods. We reviewed the medical histories with diagnoses of acute stroke –i.e. ischaemic or haemorrhagic stroke and transient ischaemic attack (TIA)– for a three-month period. Alternative diagnoses were established in doubtful stroke cases (without meeting the World Health Organisation stroke criteria). Results. Altogether there were 358 patients: 110 TIA, 191 ischaemics and 57 haemorrhagics. In all, 65 false diagnoses were selected, which represented 18.2% of the total number (41.8% of the cases of TIA) and 31.8% of the strokes admitted in the emergency department. The subtypes of false diagnoses were: 46 TIA (70.8%), 18 ischaemics (27.7%) and one haemorrhagic (1.5%). The alternative diagnoses were the following: syncope/pre-syncope in 10.8% of cases (n = 7); confusional syndrome/disorientation in 21.5% (n = 14); lowered level of consciousness in 27.7% (n = 18); generalised weakness in 6.2% (n = 4); dizziness/vertigo in 3.1% (n = 2); isolated dysarthria in 10.8% (n = 7); epileptic seizure in 6.2% (n = 4); and others in 13.8% (n = 9). A total of 71.7% could be attributed to systemic causes. The mean age was 79 years and 64.6% were females (n = 42). Computerised tomography of the head was performed in 70.8% of the cases (n = 46). A neurologist assessed 7.7% of them (n = 5). The destination on being discharged was: primary care (53.3%), visit to neurology department (31.7%), visit internal medicine department (6.7%), hospitalisation in neurology department (1.7%), hospitalisation in other specialties (1.7%), transfer (1.7%) and death (3.3%). Conclusions. False diagnoses of cerebrovascular diseases are common. In emergency departments almost half of the diagnoses of TIA may be wrong. Most false diagnoses refer to TIA (70%) and occur in elderly patients, can be attributed to systemic causes, have not been assessed by a neurologist and are referred to primary care. Hospital stroke registries that include emergency patients may be overestimated, especially in the number of cases of TIA (AU)

[Bronchoalveolar lavage findings in patients with diffuse interstitial lung disease: prospective study of a cohort of 562 patients]. / Hallazgos en el lavado broncoalveolar de pacientes con enfermedad pulmonar intersticial difusa. Estudio de una cohorte prospectiva de 562 pacientes.

OBJECTIVE: Study of the bronchoalveolar lavage (BAL) fluid in some interstitial lung diseases can reveal patterns typical to each disease and that can support the diagnosis. The objective of this study was to perform a descriptive analysis of the cytologic study and of the lymphocyte subpopulations in BAL fluid from patients with interstitial lung disease. MATERIAL AND METHODS: In this prospective, observational study of 562 patients between January 1991 and January 2005, BAL fluid was analyzed to determine the distribution of cell populations and of lymphocyte subsets: CD3, CD4, CD8, CD3(+)CD4(-)CD8(-), and CD56. RESULTS: The mean age was 53.4 years and 53.3% of the patients were women. The following diseases were studied: idiopathic pulmonary fibrosis (n=132), sarcoidosis (n=123), connective tissue diseases (n=133), cryptogenic organizing pneumonia (n=89), and extrinsic allergic alveolitis (n=85). Isolated lymphocytic alveolitis was common in sarcoidosis and extrinsic allergic alveolitis. Mixed alveolitis was the most common pattern in the other interstitial lung diseases. The CD4:CD8 ratio was the most useful parameter. It was high in sarcoidosis (median, 2.3); the ratio was low or inverted in the other interstitial lung diseases, with median values of 1.76 in idiopathic pulmonary fibrosis, 0.45 in extrinsic allergic alveolitis, 0.35 in cryptogenic organizing pneumonia, and 0.33 in the connective tissue diseases. CONCLUSIONS: BAL parameters, in association with clinical and radiologic data, help to discriminate between interstitial lung diseases. BAL should therefore be considered a very useful tool in clinical management, particularly when pulmonary biopsy is not conclusive or is not possible.

Hallazgos en el lavado broncoalveolar de pacientes con enfermedad pulmonar intersticial difusa. Estudio de una cohorte prospectiva de 562 pacientes / Bronchoalveolar Lavage Findings in Patients With Diffuse Interstitial Lung Disease: Prospective Study of a Cohort of 562 Patients

Objetivo:en determinadas enfermedades pulmonares intersticiales difusas (EPID), el estudio del lavado broncoalveolar (LBA) define patrones típicos de cada enfermedad y tiene valor como apoyo al diagnóstico. El objetivo del estudio ha sido realizar un análisis descriptivo del estudio citológico y de las subpoblaciones linfocitarias en el LBA efectuado a pacientes con EPID.Pacientes y métodos: estudio prospectivo de 562 pacientes con EPID desde 1991 hasta 2005. Se realizó un estudio de la distribución celular y de la subpoblaciones linfocitarias en el LBA: CD3, CD4, CD8, CD3+CD4−CD8− y CD56.Resultados:la edad media de los pacientes era de 53,4 años y el 53,3% eran mujeres. Se estudiaron las siguientes enfermedades: fibrosis pulmonar idiopática (n=132), sarcoidosis (n=123), enfermedades del colágeno (n=133), neumonía organizada criptogenética (n=89) y alveolitis alérgica extrínseca (n=85). Tanto en los casos de sarcoidosis como en los de alveolitis alérgica extrínseca fue frecuente la alveolitis linfocitaria aislada. En el resto de enfermedades la alveolitis mixta fue el patrón habitual. El índice CD4/CD8 fue el parámetro más útil, con un incremento en la sarcoidosis (mediana: 2,3). En el resto de las enfermedades el índice estaba invertido, con una mediana para la fibrosis pulmonar idiopática, la alveolitis alérgica extrínseca, la neumonía organizada criptogenética y la enfermedad del colágeno de 1,76; 0,45; 0,35, y 0,33, respectivamente.Conclusiones: los parámetros del LBA, junto a los datos clinicorradiológicos, ayudan a discriminar entre las EPID. Por lo tanto, debe considerarse una técnica de gran utilidad en el manejo clínico, sobre todo cuando la biopsia pulmonar no resulta diagnóstica o no es posible realizarla(AU)

Objective: Study of the bronchoalveolar lavage (BAL) fluid in some interstitial lung diseases can reveal patterns typical to each disease and that can support the diagnosis. The objective of this study was to perform a descriptive analysis of the cytologic study and of the lymphocyte subpopulations in BAL fluid from patients with interstitial lung disease.Material and methods: In this prospective, observational study of 562 patients between January 1991 and January 2005, BAL fluid was analyzed to determine the distribution of cell populations and of lymphocyte subsets: CD3, CD4, CD8, CD3+CD4−CD8−, and CD56.ResultsThe mean age was 53.4 years and 53.3% of the patients were women. The following diseases were studied: idiopathic pulmonary fibrosis (n=132), sarcoidosis (n=123), connective tissue diseases (n=133), cryptogenic organizing pneumonia (n=89), and extrinsic allergic alveolitis (n=85). Isolated lymphocytic alveolitis was common in sarcoidosis and extrinsic allergic alveolitis. Mixed alveolitis was the most common pattern in the other interstitial lung diseases. The CD4:CD8 ratio was the most useful parameter. It was high in sarcoidosis (median, 2.3); the ratio was low or inverted in the other interstitial lung diseases, with median values of 1.76 in idiopathic pulmonary fibrosis, 0.45 in extrinsic allergic alveolitis, 0.35 in cryptogenic organizing pneumonia, and 0.33 in the connective tissue diseases.Conclusions: BAL parameters, in association with clinical and radiologic data, help to discriminate between interstitial lung diseases. BAL should therefore be considered a very useful tool in clinical management, particularly when pulmonary biopsy is not conclusive or is not possible(AU)

Management of invasive Candida infections in non-neutropenic critically ill patients: from prophylaxis to early therapy.

Echinocandins are the treatment of choice for patients with severe forms of candidaemia, including neutropenic patients and those episodes presenting with shock. There is little distinction between the three available echinocandins (caspofungin, anidulafungin and micafungin), but there is more clinical experience with caspofungin. Identifying patients who will benefit from early antifungal therapy using clinical tools such as the 'Candida Score' is an interesting strategy that may reduce the high mortality in critically ill patients with invasive fungal infections.

[Prophylaxis of venous thromboembolism]. / Profilaxis de la enfermedad tromboembólica venosa.

The recommendations on venous thromboprophylaxis have been updated on the basis of current evidence reviewed by a multidisciplinary team. The problem has been approached with regard to its relevance in both surgical and nonsurgical patients. It should be noted that these recommendations were drawn up for use in Spain and, therefore, should be implemented with the drugs and therapeutic practices authorized and generally accepted in this country.

Profilaxis de la enfermedad tromboembólica venosa / Prophylaxis of venous thromboembolism

Un equipo multidisciplinario ha realizado una actualización de recomendaciones en la profilaxis de la enfermedadtromboembólica venosa basándose en las evidencias disponiblesactualmente. Se ha abordado la problemática tanto delpaciente médico como quirúrgico. Hay que puntualizar queesta Normativa está planteada para su utilización en el ámbitode España y, por lo tanto, debe aplicarse con los fármacosautorizados y las prácticas terapéuticas más aceptadasen este país (AU)

The recommendations on venous thromboprophylaxis have been updated on the basis of current evidence reviewed by a multidisciplinary team. The problem has been approachedwith regard to its relevance in both surgical and non surgical patients. It should be noted that these recommendations were drawn up for use in Spain and, therefore, should be implemented with the drugs and therapeutic practices authorized and generally accepted in this country (AU)

Mortality and morbidity attributable to inadequate empirical antimicrobial therapy in patients admitted to the ICU with sepsis: a matched cohort study.

OBJECTIVES: To determine the attributable mortality and excess length of stay (LOS) associated with the use of inadequate empirical antimicrobial therapy in patients with sepsis at admission to the intensive care unit (ICU). METHODS: A retrospective matched cohort study was performed using a prospectively collected database at a 40 bed general ICU at a university public hospital. Patients who received inadequate antimicrobial therapy at admission to the ICU (exposed) were matched with controls (unexposed) on the basis of origin of sepsis, inflammatory response at admission, surgical or medical status, hospital- or community-acquired sepsis, APACHE II score (+/-2 points) and age (+/-10 years). Clinical outcome was assessed by in-hospital mortality, and this analysis was also performed in those pairs without nosocomial infection in the ICU. RESULTS: Eighty-seven pairs were successfully matched. Fifty-nine exposed patients died [67.8% mortality (95% CI, 58.0-77.6%)] and 25 unexposed controls died [28.7% mortality (95% CI, 19.2-38.2%)] (P < 0.001). Excess in-hospital mortality was estimated to be 39.1%. The rate of nosocomial infection was significantly higher in patients with inadequate empirical therapy (16.1%) than in those treated empirically with adequate antibiotics (3.4%) (P = 0.013). Excess in-hospital mortality was 31.4% after excluding those 17 pairs that developed a nosocomial infection in the ICU. Inadequate antimicrobial therapy was associated with a significant increment in duration of hospitalization (15 days in surviving pairs). CONCLUSIONS: Inadequate antimicrobial therapy at admission to the ICU with sepsis is associated with excess mortality and increases LOS.

[Experience with the Norwood operation for hypoplastic left heart syndrome]. / Resultados de la intervención de Norwood para el síndrome del corazón izquierdo hipoplásico.

INTRODUCTION AND OBJECTIVES: To describe our experience and to identify risk factors for in-hospital mortality. METHODS: Between October 1991 and June 2005, 42 children underwent the Norwood procedure. In the first 30 patients, pulmonary circulation was established using a modified Blalock-Taussig shunt (Group 1), while a right ventricle to pulmonary artery conduit was used in the remaining 12 (Group 2). Preoperative anatomic features and procedural factors were analyzed with respect to their impact on mortality. Postoperatively, data were collected on arterial blood pressure, arterial and venous oxygen saturation, arterial pH, venous pCO2, the PaO2/FiO2 ratio, tissue oxygen extraction, and dead space fraction. The association between each individual variable and mortality was investigated. RESULTS: Thirty patients (71.4%) had both aortic and mitral atresia, eight (19%) had either aortic or mitral atresia, and four (9.5%) had no valvular atresia. There was no statistically significant difference in postoperative mortality between the groups 1 and 2 (12/22 [54.5%] vs 7/12 [58.3%]; P=.56). The only significant risk factor for in-hospital mortality was a longer cardiopulmonary bypass time (P=.01) and, for intraoperative mortality, primary rather than delayed sternal closure (P=.004). Venous pCO2, the mean dead space fraction, and tissue oxygen extraction all tended to be higher among infants who died, but the difference was not statistically significant. CONCLUSIONS: Use of a right ventricle to pulmonary artery conduit did not improve postoperative survival. Both a long cardiopulmonary bypass time and primary sternal closure were associated with increased mortality.

Resultados de la intervención de Norwood para el síndrome del corazón izquierdo hipoplásico / Experience with the norwood operation for hypoplastic left heart syndrome

Introducción y objetivos. Describir nuestra experiencia e identificar factores de riesgo de mortalidad hospitalaria. Métodos. Entre octubre de 1991 y junio de 2005 intervinimos a 42 niños con la técnica de Norwood. Los 30 primeros recibieron una fístula de Blalock-Taussig (grupo 1) y los 12 restantes, un conducto entre el ventrículo derecho y la arteria pulmonar (grupo 2). Se analizaron los factores anatómicos y de la técnica con respecto a la mortalidad. Se recogieron variables del postoperatorio, incluidas la presión arterial, la saturación arterial y venosa de oxígeno, el pH arterial, la pCO2 venosa, la relación PaO2/FiO2, la extracción tisular de oxígeno y el espacio muerto, para estudiar su asociación con la mortalidad. Resultados. En total, 30 (71,4%) pacientes tenían atresia aórtica y mitral; 8 (19%) tenían atresia aórtica o mitral y 4 (9,5%) no tenían atresia. No hubo diferencias significativas en la mortalidad postoperatoria entre los grupos 1 y 2 (12/22 [54,5%] frente a 7/12 [58,3%]; p = 0,56). El único factor de riesgo de mortalidad hospitalaria fue un tiempo de circulación extracorpórea prolongado (p = 0,01), y el de mortalidad intraoperatoria, el cierre primario del esternón (p = 0,004). La pCO2 venosa, el espacio muerto pulmonar y la extracción tisular de oxígeno fueron superiores en los niños fallecidos, pero las diferencias no fueron significativas. Conclusiones. El uso de un conducto entre el ventrículo derecho y la arteria pulmonar no mejoró la supervivencia postoperatoria. Un tiempo de circulación extracorpórea prolongado y el cierre primario del esternón se asociaron con un aumento de la mortalidad (AU)

Introduction and objectives. To describe our experience and to identify risk factors for in-hospital mortality. Methods. Between October 1991 and June 2005, 42 children underwent the Norwood procedure. In the first 30 patients, pulmonary circulation was established using a modified Blalock-Taussig shunt (Group 1), while a right ventricle to pulmonary artery conduit was used in the remaining 12 (Group 2). Preoperative anatomic features and procedural factors were analyzed with respect to their impact on mortality. Postoperatively, data were collected on arterial blood pressure, arterial and venous oxygen saturation, arterial pH, venous pCO2, the PaO2/FiO2 ratio, tissue oxygen extraction, and dead space fraction. The association between each individual variable and mortality was investigated. Results. Thirty patients (71.4%) had both aortic and mitral atresia, eight (19%) had either aortic or mitral atresia, and four (9.5%) had no valvular atresia. There was no statistically significant difference in postoperative mortality between the groups 1 and 2 (12/22 [54.5%] vs 7/12 [58.3%]; P=.56). The only significant risk factor for in-hospital mortality was a longer cardiopulmonary bypass time (P=.01) and, for intraoperative mortality, primary rather than delayed sternal closure (P=.004). Venous pCO2, the mean dead space fraction, and tissue oxygen extraction all tended to be higher among infants who died, but the difference was not statistically significant. Conclusions. Use of a right ventricle to pulmonary artery conduit did not improve postoperative survival. Both a long cardiopulmonary bypass time and primary sternal closure were associated with increased mortality (AU)

Cerebral perfusion pressure and risk of brain hypoxia in severe head injury: a prospective observational study.

INTRODUCTION: Higher and lower cerebral perfusion pressure (CPP) thresholds have been proposed to improve brain tissue oxygen pressure (PtiO2) and outcome. We study the distribution of hypoxic PtiO2 samples at different CPP thresholds, using prospective multimodality monitoring in patients with severe traumatic brain injury. METHODS: This is a prospective observational study of 22 severely head injured patients admitted to a neurosurgical critical care unit from whom multimodality data was collected during standard management directed at improving intracranial pressure, CPP and PtiO2. Local PtiO2 was continuously measured in uninjured areas and snapshot samples were collected hourly and analyzed in relation to simultaneous CPP. Other variables that influence tissue oxygen availability, mainly arterial oxygen saturation, end tidal carbon dioxide, body temperature and effective hemoglobin, were also monitored to keep them stable in order to avoid non-ischemic hypoxia. RESULTS: Our main results indicate that half of PtiO2 samples were at risk of hypoxia (defined by a PtiO2 equal to or less than 15 mmHg) when CPP was below 60 mmHg, and that this percentage decreased to 25% and 10% when CPP was between 60 and 70 mmHg and above 70 mmHg, respectively (p < 0.01). CONCLUSION: Our study indicates that the risk of brain tissue hypoxia in severely head injured patients could be really high when CPP is below the normally recommended threshold of 60 mmHg, is still elevated when CPP is slightly over it, but decreases at CPP values above it.

[Risk factors associated with arterial switch operation for transposition of the great arteries]. / Factores de riesgo de la corrección anatómica para la transposición de grandes arterias.

INTRODUCTION AND OBJECTIVES: The present study was undertaken to determine the risk factors for early mortality following an arterial switch operation. PATIENTS AND METHOD: From January 1994 through October 2003, 78 pediatric patients underwent surgical repair. Simple transposition was present in 48 patients (61.5%), 29 (37.2%) had an associated ventricular septal defect, and one had a Taussig-Bing anomaly. The risk factors analyzed were: the patient's age and weight at the time of the intervention, repair of a coexisting ventricular septal defect, coronary artery anatomical pattern, duration of cardiopulmonary bypass, duration of aortic cross-clamping, and duration of circulatory arrest. All factors were evaluated for strength of association with the duration of mechanical ventilation, the length of intensive care unit stay, and mortality. RESULTS: Overall, the early mortality rate was 9% (7/78). Some 14 patients (17.9%) underwent simultaneous repair of a ventricular septal defect. Patients with an intramural coronary artery (n=3, 3.8%) or a single coronary ostium (n=5, 6.4%) were the only ones who had a significant (P<.05) mortality risk, at 50% (4/8). Circulatory arrest was implemented in 53 (68%) patients. There were significant correlations between the duration of circulatory arrest and the ventilator support time (r=0.3, P<.05) and the duration of stay in the intensive care unit (r=0.3, P<.05). CONCLUSIONS: The risk of early death was increased when more complex coronary artery anatomical variants were present. As the period of circulatory arrest lengthened, the mechanical ventilation time and duration of intensive care unit stay increased.

Factores de riesgo de la corrección anatómica para la transposición de grandes arterias / Risk factors associated with arterial switch operation for transposition of the great arteries

Introducción y objetivos. Este estudio se realizó para determinar los factores de riesgo que pueden influir en la mortalidad precoz después de la corrección anatómica. Pacientes y método. Entre enero de 1994 y octubre de 2003 intervenimos a 78 pacientes; 48 (61,5%) eran transposiciones simples, 29 (37,2%) presentaban asociada una comunicación interventricular y 1 tenía una anomalía de Taussing-Bing. Se analizaron la edad y el peso en el momento de la intervención, el cierre o no de la comunicación interventricular, la anatomía coronaria y los tiempos de circulación extracorpórea, la anoxia miocárdica y la parada circulatoria. Evaluamos la relación entre estas variables con los tiempos de ventilación mecánica, la estancia en la unidad de cuidados intensivos pediátricos y la mortalidad. Resultados. De los 78 niños fallecieron 7 (9%). En 14 (17,9%) se cerró, además, una comunicación interventricular. Los que presentaron una arteria coronaria intramural (n = 3, 3,8%) o tenían un orificio coronario único (n = 5, 6,4%) fueron los que tuvieron una mayor mortalidad (4/8, 50%) (p < 0,05). En 53 niños (68%) se realizó parada circulatoria; el tiempo de parada se correlacionó de forma directa tanto con las horas de ventilación mecánica (r = 0,3; p < 0,05) como con los días de estancia (r = 0,3; p < 0,05). Conclusiones. Las variantes más complejas en la anatomía coronaria se asociaron con un mayor riesgo de muerte precoz. La duración de la parada circulatoria influyó en los tiempos de ventilación mecánica y en la estancia en cuidados intensivos

Introduction and objectives. The present study was undertaken to determine the risk factors for early mortality following an arterial switch operation. Patients and method. From January 1994 through October 2003, 78 pediatric patients underwent surgical repair. Simple transposition was present in 48 patients (61.5%), 29 (37.2%) had an associated ventricular septal defect, and one had a Taussig-Bing anomaly. The risk factors analyzed were: the patient's age and weight at the time of the intervention, repair of a coexisting ventricular septal defect, coronary artery anatomical pattern, duration of cardiopulmonary bypass, duration of aortic cross-clamping, and duration of circulatory arrest. All factors were evaluated for strength of association with the duration of mechanical ventilation, the length of intensive care unit stay, and mortality. Results. Overall, the early mortality rate was 9% (7/78). Some 14 patients (17.9%) underwent simultaneous repair of a ventricular septal defect. Patients with an intramural coronary artery (n=3, 3.8%) or a single coronary ostium (n=5, 6.4%) were the only ones who had a significant (P<.05) mortality risk, at 50% (4/8). Circulatory arrest was implemented in 53 (68%) patients. There were significant correlations between the duration of circulatory arrest and the ventilator support time (r=0.3, P<.05) and the duration of stay in the intensive care unit (r=0.3, P<.05). Conclusions. The risk of early death was increased when more complex coronary artery anatomical variants were present. As the period of circulatory arrest lengthened, the mechanical ventilation time and duration of intensive care unit stay increased