A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

OBJECTIVE: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. DESIGN: A secondary analysis derived from multicenter, observational study. SETTING: Critical Care Units. PATIENTS: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. INTERVENTIONS: Corticosteroids vs. no corticosteroids. MAIN VARIABLES OF INTEREST: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. RESULTS: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR=0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. CONCLUSION: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients.

Objective: To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes. Design: A secondary analysis derived from multicenter, observational study. Setting: Critical Care Units. Patients: Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain. Interventions: Corticosteroids vs. no corticosteroids. Main variables of interest: Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes. Results: A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR = 0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality. Conclusion: Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

Objetivo: Evaluar si el uso de corticoesteroides (CC) se asocia con la mortalidad en la unidad de cuidados intensivos (UCI) en la población global y dentro de los fenotipos clínicos predeterminados. Diseño: Análisis secundario de estudio multicéntrico observacional. Ámbito: UCI. Pacientes: Pacientes adultos con COVID-19 confirmado ingresados en 63 UCI de España. Intervención: Corticoides vs. no corticoides. Variables de interés principales: A partir del análisis no supervisado de grupos, 3 fenotipos clínicos fueron derivados y clasificados como: A grave, B crítico y C potencialmente mortal. Se efectuó un análisis multivariado después de un propensity optimal full matching (PS) y una regresión ponderada de Cox (HR) y análisis de Fine-Gray (sHR) para evaluar el impacto del tratamiento con CC sobre la mortalidad en la población general y en cada fenotipo clínico. Resultados: Un total de 2.017 pacientes fueron analizados, 1.171 (58%) con CC. Después del PS, el uso de CC no se relacionó significativamente con la mortalidad en UCI (OR: 1,0; IC 95%: 0,98-1,15). Los CC fueron administrados en 298/537 (55,5%) pacientes del fenotipo A y no se observó asociación significativa con la mortalidad (HR = 0,85; 0,55-1,33). Un total de 338/623 (54,2%) pacientes del fenotipo B recibieron CC sin efecto significativo sobre la mortalidad (HR = 0,72; 0,49-1,05). Por último, 535/857 (62,4%) pacientes del fenotipo C recibieron CC. En este fenotipo, se evidenció un efecto protector de los CC sobre la mortalidad HR (0,75; 0,58-0,98). Conclusión: Nuestros hallazgos alertan sobre el uso indiscriminado de CC a dosis moderadas en todos los pacientes críticos con COVID-19. Solamente pacientes con elevado estado de inflamación podrían beneficiarse con el tratamiento con CC.

Laboratory studies on secondary organic aerosol formation from crude oil vapors.

Airborne measurements of aerosol composition and gas phase compounds over the Deepwater Horizon (DWH) oil spill in the Gulf of Mexico in June 2010 indicated the presence of high concentrations of secondary organic aerosol (SOA) formed from organic compounds of intermediate volatility. In this work, we investigated SOA formation from South Louisiana crude oil vapors reacting with OH in a Potential Aerosol Mass flow reactor. We use the dependence of evaporation time on the saturation concentration (C*) of the SOA precursors to separate the contribution of species of different C* to total SOA formation. This study shows consistent results with those at the DWH oil spill: (1) organic compounds of intermediate volatility with C* = 10(5)-10(6) µg m(-3) contribute the large majority of SOA mass formed, and have much larger SOA yields (0.37 for C* = 10(5) and 0.21 for C* = 10(6) µg m(-3)) than more volatile compounds with C*≥10(7) µg m(-3), (2) the mass spectral signature of SOA formed from oxidation of the less volatile compounds in the reactor shows good agreement with that of SOA formed at DWH oil spill. These results also support the use of flow reactors simulating atmospheric SOA formation and aging.

Severe rhabdomyolysis after allogeneic transplantation of facial structures: a case report.

We present a patient with panfacial neurofibromatosis type 1 who underwent allogeneic transplantation of facial structures, which was complicated by severe rhabdomyolysis and temporary oligoanuria. Because of his underlying disease, this 35 year-old man, weighing 68 kg and with a body mass index (BMI) of 27, had undergone 17 operations for resection modeling of hypertrophied tissues, either alone or combined with static suspension techniques. He finally underwent allogeneic transplantation of facial structures. In the early hours of the postoperative period, in the context of a systemic inflammatory response syndrome, he experienced severe rhabdomyolysis, with elevation of the muscle enzyme creatine kinase producing a minor impact on kidney function. The patient was discharged home at 12 weeks after the transplantation.

Kidney failure after heart transplantation.

BACKGROUND AND PURPOSE: Heart transplantation is a procedure with a high mortality rate. Altered kidney function (AKF) after a heart transplant is common. The purpose of this study was to determine the incidence of and associated factors for renal dysfunction among patients who underwent heart transplantation in our hospital between January 2006 and November 2008. PATIENTS AND METHODS: This retrospective observational study was performed on all patients receiving a heart transplant between January 1, 2006 and November 15, 2008. The following variables were recorded: patient comorbidities, indication, presurgical urea and creatinine levels, donor variables, surgical procedure, and postoperative features. RESULTS: A total of 54 heart transplantations were performed with 68.5% of patients being male. The average age at transplant was 49.52 years (±13.45 y) and the mean weight 72.5 kg (±14.8 kg). Overall mortality was 28.30%. Of the 54 patients, 70.4% showed AKF during the first week after transplantation; 30.61% were in stage III according to the Acute Kidney Injury classification. There were no statistically significant differences between the group of patients with versus without renal failure, except for the extracorporeal surgery time, which was significantly longer among those patients who had AKF, and glycemia, which was also higher in the immediate postoperative period. Analysis of patient mortality showed no significant differences for the patients with AKF (80% vs 68.4%; P=31). CONCLUSIONS: The rate of acute kidney failure was high (70.4%), as was the use of chronic renal replacement therapy (28.85%), but it decreased considerably when followed over time.

Considerations regarding major bleeding after cardiac transplantation.

Postoperative bleeding is one of the most frequent complications after cardiac surgery, leading to longer stays in the intensive care unit (ICU) and the hospital as well as increased morbidity and mortality. We designed an observational prospective study to evaluate early complications after cardiac transplantation, focusing on major bleeding and transfusion requirements. We also evaluated whether massive transfusion was related to increased morbidity and mortality. In patients who received ≥6 blood units, we observed significant differences regarding the need for continuous renal replacement techniques (50% vs 12.5%; P=.01) and ICU mortality (33.3% vs 4%; P=.01). This difference in mortality was also observed when comparing plasma transfusion requirements (35.3% vs 9.4%; P=.04). The overall mortality rate was 24.50%, showing significant differences in patients with massive transfusion (83.3% vs 37.8%; P=.008). In conclusion, perioperative bleeding and massive transfusion were associated with increased morbidity and mortality in this group of patients, which may prompt a review of surgical procedures and the introduction of new techniques, such as thromboelastography.

Dolor persistente tras hernioplastia inguinal: estudio descriptivo a largo plazo / No disponible

Introducción: Dolor crónico es aquel que permanece tras 3 meses desde la intervención quirúrgica. De etiología multifactorial, puede llegar a ser invalidante para el paciente. Objetivos: Conocer, en nuestro medio, la prevalencia del dolor crónico posthernioplastia inguinal en cirugía programada y régimen ambulatorio. Material y métodos: Estudio descriptivo retrospectivo de los pacientes diagnosticados de hernia inguinal e intervenidos de manera programada en cirugía mayor ambulatoria entre enero de 2000 y diciembre de 2006. Dolor inmediato: primeras 72 horas; dolor agudo: 3 primeros meses; dolor crónico: más de 3 meses. Seguimiento: llamada telefónica a las 24 y 48 horas del alta, revisión en consulta al mes y llamada telefónica al año. Resultados: 3.649 pacientes (81,70% hombres), edad media 54,15 años. ASA II 63,55%. Dolor inmediato en el 85% delos pacientes, que cedió con la analgesia pautada; dolor agudo en el 3%, inyectándose corticoide y anestésico local cuando el dolor no cedía pasadas 4 semanas en 3 pacientes; dolor crónico en el 0% de los pacientes seguidos durante un año. Discusión: Durante el primer mes del postoperatorio sólo están indicados analgésicos orales. Pasado este periodo y ante la permanencia de dolor, u na alternativa a la analgesia pautada puede ser la inyección de corticoide y anestésico local en lazona intervenida. Conclusión: El dolor inmediato tras la hernioplastia inguinal programada en régimen ambulatorio así como el producido en los 3 primeros meses, precisa únicamente analgesia oral. Es nula la prevalencia de dolor crónico en nuestra serie (AU)

Introduction: Chronic pain is pain that persists 3 months after the surgical procedure. Of multifactorial etiology, it can be disabling for the patient. Objetives: To determine, in our environment, the prevalence of chronic pain after inguinal hernioplasty scheduled as ambulatory surgery. Material and methods: A retrospective study of patients diagnosed with inguinal hernia and who underwent ambulatory surgery between January 2000 and December 2006. Immediate pain: at 72hours; severe pain: up to 3 months; chronic pain: more than 3months. Follow-up: telephone call at 24 and 48 hours after discharge, clinical visit one month after and phone call one year later. Results: 3,649 patients (81.70% male), mean age 54.15years. ASA II 63.55%. Immediate pain in the first 48 hours in 85% of patients, which was controlled with analgesia; severe pain in 3%, in which steroids and local anaesthetic injected in 1-2 sessions were given when the pain did not abate after 4 weeks in 3 patients; chronic pain in 0% of the patients followed for one year. Discussion: During the first month after surgery only oral analgesics are indicated. After this period and if there is persistence of pain, an alternative to analgesia may be the injection of corticosteroids and a local anaesthetic. Conclusion: The immediate pain after inguinal hernia in elective and ambulatory surgery as well as until the first 3 months require only oral analgesia. Is zero the prevalence of chronic pain in our series (AU)

Implantación de catéteres de diálisis peritoneal: Nuestra experiencia a corto y largo plazo / No disponible

Introducción: Experiencia a corto y a largo plazo en la implantación de catéteres de diálisis peritoneal y objetivos establecidos para instaurar la técnica en régimen de cirugía mayor ambulatoria(CMA).Material y métodos: Estudio retrospectivo durante ocho años. Dos grupos: catéteres tipo Tenckhoff con dos cuff y catéteres tipo Tenckhoff con dos cuff y un lastre final. Peculiaridad quirúrgica: introducción del catéter en una solución antibiótica. Las complicaciones se han dividido en corto y largo plazo en función de que aparecieran o no en la primera semana de implantación. Resultados: Causa más frecuente conocida de insuficiencia renal crónica: diabetes mellitus (9,8%). En el 33,1% (41 catéteres)no hubo ninguna complicación, y destacan el dolor a corto plazo(8,9%) y la peritonitis a largo plazo (8,1%). El 78,4% de los inicialmente implantados no precisaron ser recambiados. Conclusiones: La colocación del catéter peritoneal debe ser realizada en quirófano. La diálisis peritoneal es una técnica segura, eficaz y simple tanto para el cirujano como para el paciente. Presenta escasas complicaciones, fundamentalmente dolor y peritonitis. El catéter se recambia cuando funciona mal o fuga. No existen en la literatura estudios que reflejen la introducción del catéter en una solución antibiótica previo a su colocación. Puede implantarse en régimen de CMA (AU)

Introduction: Our short and long term experience in the implantation of peritoneal catheters is exposed in this study and whether the aims established for ambulatory surgery are fulfilled. Material and methods: An eight year retrospective study. Two groups: catheters type Tenckhoff with two cuffs and catheters type Tenckhoff with two cuffs and a ballast on the end. Surgical peculiarity: the introduction of the catheter in an antibiotic solution. The complications were divided in short and long term depending on when they appeared during the first week of implantation or not. Results: The most frequent reason for chronic renal insufficiency was: diabetes mellitus (9.8%). In 33.1% of cases (41catheters) there were no complications, and only pain on the short-term (8.9%) and peritonitis on the long-term (8.1%).78.43% of the initially implanted catheters did not need to be replaced. Conclusions: The placement of the peritoneal catheter must be done in the operating room.Peritoneal dialysis is a sure, effective and simple technique for the surgeon and for the patient. It presents few complications,mainly pain and peritonitis. The catheter is replaced when it works badly or leaks. There are no studies in the literature that reflectthe introduction of the catheter in an antibiotic solution before its placement. It can be implanted as an AS procedure (AU)

[Evaluation and maintenance of heart donors]. / Evaluación y mantenimiento del donante cardíaco.

Heart transplantation is currently the best treatment option to improve hope and quality of life in patients with terminal heart failure that is refractory to conventional treatment. The scarcity of donors remains a difficult problem and is the main factor limiting the number of transplants that can be performed. Given the current situation of stagnation and disparity between the number of potential organ donors, actual donors, and patients requiring transplants, we need effective strategies to reduce the differences between supply and demand and to ensure the best possible prognosis in organ recipients. These strategies should aim to ensure optimal donor selection. Likewise, it is essential to increase the number of potential donors by widening the criteria for donation and to improve our ability to take advantage of suboptimal donors. Moreover, we need to achieve acceptable physiological maintenance of donated organs. All these actions, together with the standardization of future treatments like hormone replacement therapy and genomic evaluation, will undoubtedly lead to an increase in the rate of transplants in the short and mid term, because the option of heart transplantation continues to have only slight repercussions in the high prevalence of terminal heart failure in our environment.

Evaluación y mantenimiento del donante cardíaco / Evaluation and maintenance of heart donors

Actualmente el trasplante de corazón es la mejor opción terapéutica para aumentar la esperanza y la calidad de vida en los pacientes con insuficiencia cardíaca terminal refractaria al tratamiento convencional. La escasez de donantes es un problema difícil y pendiente de resolver, y constituye el principal factor limitante en el incremento de las cifras de trasplante. En la actual situación de estancamiento y disparidad entre el número de donantes de órganos potenciales, donantes reales y las necesidades clínicas de implantación se requieren estrategias efectivas para reducir esta diferencia y para mantener las mejores posibilidades de éxito en el pronóstico de los receptores. Estas estrategias deben ir dirigidas hacia una óptima selección del donante, así como hacia un incremento del número de potenciales donantes mediante la ampliación de los criterios de aceptación de éstos y hacia una mejora en el aprovechamiento de los donantes subóptimos. Además, debemos lograr un mantenimiento fisiológico adecuado del órgano. Todo este tipo de actuaciones, junto con la estandarización de tratamientos futuros (tratamiento hormonal de reemplazamiento o valoración genómica), nos tiene que llevar, sin duda, a un aumento en las cifras de transplantes a corto y a medio plazo, ya que la opción del transplante cardíaco sigue teniendo escasa repercusión en el gran alto grado de prevalencia de la insuficiencia cardíaca terminal en nuestro medio (AU)

Heart transplantation is currently the best treatment option to improve hope and quality of life in patients with terminal heart failure that is refractory to conventional treatment. The scarcity of donors remains a difficult problem and is the main factor limiting the number of transplants that can be performed. Given the current situation of stagnation and disparity between the number of potential organ donors, actual donors, and patients requiring transplants, we need effective strategies to reduce the differences between supply and demand and to ensure the best possible prognosis in organ recipients. These strategies should aim to ensure optimal donor selection. Likewise, it is essential to increase the number of potential donors by widening the criteria for donation and to improve our ability to take advantage of suboptimal donors. Moreover, we need to achieve acceptable physiological maintenance of donated organs. All these actions, together with the standardization of future treatments like hormone replacement therapy and genomic evaluation, will undoubtedly lead to an increase in the rate of transplants in the short and mid term, because the option of heart transplantation continues to have only slight repercussions in the high prevalence of terminal heart failure in our environment (AU)

Application of the McCluskey Index to predict blood product requirements during liver transplantation.

BACKGROUND: A recent study proposed a risk index (McCluskey index) based on 7 parameters to identify the transfusion needs of patients during surgery and in the first 24 hours postoperation. The initial objective of our study was to validate this predictor for blood product transfusions. PATIENTS AND METHODS: We undertook a retrospective, observational study of all liver transplant patients between January 1, 2005 and December 31, 2006. The following variables were recorded for each patient: age, gender, patient comorbidity, biochemical values prior to liver transplantation, and transfusion needs. RESULTS: Comparing the transfusion needs of those patients with scores <5 with those of scores >/=5, we observed significant differences in terms of the use of red blood cell concentrates, plasma, and platelets, both during the first 24 hours and in the total number. The index sensitivity was 80% (95% confidence interval [CI]: 71.23-88.76), with a specificity of 84.21% (95% CI: 67.81-100), where the positive predictive value was 95.52% (95% CI: 90.57-100.4) and the negative predictive value was 50% (95% CI: 32.67-67.32). CONCLUSION: The McCluskey index showed sufficient sensitivity and specificity to predict which patients will require a massive transfusion.

Comparison between two drugs on the hemodynamic evaluation of pulmonary hypertension prior to heart transplantation.

INTRODUCTION: Invasive estimation of pulmonary pressure is part of the usual protocol prior to heart transplantation. The aim of this study was to compare the results of 2 different vasodilators, nitric oxide (NO) and prostacyclin, in an acute vasodilator test (AVT) for patients with pulmonary venous hypertension. MATERIALS AND METHODS: From January 2000 to December 2006, 94 right-sided heart catheterizations were performed in our center within pretransplantation evaluations. AVT was performed if the mean pulmonary artery pressure (mPAP) >35 mm Hg or if the pulmonary vascular resistance (PVR) was >4 Wood units (WU). Epoprostenol was administered to 40 patients, NO to 6 patients, and both agents to 8 patients. RESULTS: A significant decrease in both mPAP and PVR was shown with maximum doses of epoprostenol, with an average variation of 8.96 mm Hg in mPAP (P < .001) and 3.26 WU in PVR (P < .001). An increased cardiac output (CO) was observed with epoprostenol, with a mean difference of 1.9 L/min (P < .001) at maximum compared with baseline doses. A tendency for the mPAP and PVR to decrease was also observed with maximum NO doses, with mean decreases of mPAP and PVR of 5.62 mm Hg and 1.14 WU, respectively. A tendency for CO to decrease was observed with NO (0.75 L/min; P = .039). CONCLUSIONS: In our experience, NO is the best drug for AVT due to its pulmonary tree selectivity. A study with epoprostenol was complementary; both drugs can be used in these patients prior to heart transplantation.