Descripción de un brote polimicrobiano en una unidad de cuidados intensivos durante la ola pandémica de COVID-19 de marzo de 2020 / No disponible

INTRODUCCIÓN: La ola pandémica de COVID-19 de marzo de 2020 mermó las medidas de control de infección en las UCI. Se describe un brote polimicrobiano, sus posibles factores de riesgo, relación con la COVID-19 y medidas que facilitaron su control. MÉTODOS: estudio observacional longitudinal retrospectivo. RESULTADOS: se estudiaron 149 pacientes, 23 casos presentaron microorganismos de interés, 9 más de uno. Se aislaron 15 Klebsiella pneumoniae BLEE, 5 KPC, 8 hongos filamentosos y 5 bacilos gramnegativos no fermentadores. La tasa de ataque fue de 0,154 siendo superior para ingresos COVID-19 (0,262) frente a otros motivos (0,015), con una diferencia de 0,247 (0,148-0,345; p < 0,001). Se implementaron medidas de control sobre los riesgos detectados. CONCLUSIÓN: ser paciente COVID-19 se asoció con mayor riesgo de ser caso, consideramos como posibles desencadenantes el mayor contacto requerido con equipos de protección y la pérdida temporal de control sobre la multirresistencia, tanto de información como de competencia

INTRODUCTION: The pandemic wave of COVID-19 in March 2020 undermined compliance with infection control measures in ICUs. A polymicrobial outbreak, its possible risk factors, relationship with COVID-19 and measures that facilitated its control are described. METHODS: retrospective longitudinal observational study. RESULTS: 149 patients were studied, 23 cases presented microorganisms of interest, 9 more than one. 15 Klebsiella pneumoniae ESBL, 5 KPC, 8 filamentous fungi and 5 non-fermenting gram-negative bacilli were isolated. The attack rate was 0.154, being higher for patients admitted for COVID-19 (0.262) compared to other reasons (0.015), with a difference of 0.247 (0.148-0.345; p < 0.001). Control measures were implemented on the risks detected. CONCLUSION: being a COVID-19 patient was associated with a higher risk of being a case, we consider as possible triggers the greater contact required with protective equipment and the temporary loss of control over multidrug resistance, both of information and of competence

Función eréctil después de cistectomía con preservación neurovascular / Erectile Function After Cystectomy With Neurovascular Preservation

Objetivos: Estudiar la utilidad de la preservación neurovascular para la erección postoperatoria en la cistectomía radical. Materiales y métodos: Análisis retrospectivo de 44 cistectomias realizadas en nuestro centro entre enero de 2006 y diciembre de 2009 en hombres menores de 65 años. En 11 casos se hizo preservación neurovascular. Hemos analizado la edad, el índice de masa corporal, la indicación quirúrgica, la derivación urinaria, el uso de i-PDE5 o alprostadil, y la continencia diurna y nocturna. La erección se midió con el Erection Hardness Score (EHS). Resultados: La erección postoperatoria espontánea en el grupo con preservación fue del 44,4% EHS 4, del 33,3% EHS 3 y del 22,3% EHS 1 (alcanzaron EHS 3 o 4 con alprostadil). En el grupo sin preservación el 4,5% alcanzó EHS 4 espontáneamente. El otro 95,5% tenía EHS 0 (el 4,5% alcanzó EHS 3 con tadalafilo 20 mg y el 9% con inyecciones intracavernosas). Las variables edad (p = 0,001) y preservación neurovascular (p < 0,001) se encontraron relacionadas con la erección postoperatoria. En el análisis multivariado la preservación mantuvo la significación estadística. Conclusiones: Los resultados funcionales con la preservación en la cistectomía son prometedores. La preservación debe ser considerada en pacientes jóvenes sin disfunción eréctil (AU)

Objectives: To study the utility of neurovascular preservation for postoperative erection in radical cystectomy. Materials and methods: Retrospective analysis of 44 cystectomies performed at our center between January 2006-December 2009 in men < 65 years. In 11 cases a neurovascular preservation was done. We analyzed age, BMI, indication for surgery, urinary diversion, use of i-PDE5 or alprostadil, and daytime and nighttime continence. Erection Hardness Score (EHS) was used to assess erectile function. Results: Spontaneous postoperative erectile function in preservation group was 44,4% EHS 4, 33,3% EHS 3 and 22,3% EHS 1 (achieving EHS 3 or 4 with alprostadil). In the non preservation group, 4,5% achieved EHS 4 spontaneously. The other 95,5% had EHS 0 (4,5% achieved EHS 3 with tadalafil 20 mg and 9% with intracavernous injections). Variables age (P = 0.001) and nerve-sparing surgery (P < 0.001) were related to postoperative erectile function recovery. In the multivariate analysis, nerve-sparing surgery remained statisticaly significant. Conclusions: The functional results in preserving cystectomy are promising. The preservation should be considered in young patients without erectile dysfunction (AU)

Erectile function after cystectomy with neurovascular preservation.

OBJECTIVES: To study the utility of neurovascular preservation for postoperative erection in radical cystectomy. MATERIALS AND METHODS: Retrospective analysis of 44 cystectomies performed at our center between January 2006-December 2009 in men <65 years. In 11 cases a neurovascular preservation was done. We analyzed age, BMI, indication for surgery, urinary diversion, use of i-PDE5 or alprostadil, and daytime and nighttime continence. Erection Hardness Score (EHS) was used to assess erectile function. RESULTS: Spontaneous postoperative erectile function in preservation group was 44,4% EHS 4, 33,3% EHS 3 and 22,3% EHS 1 (achieving EHS 3 or 4 with alprostadil). In the non preservation group, 4,5% achieved EHS 4 spontaneously. The other 95,5% had EHS 0 (4,5% achieved EHS 3 with tadalafil 20 mg and 9% with intracavernous injections). Variables age (P=.001) and nerve-sparing surgery (P<.001) were related to postoperative erectile function recovery. In the multivariate analysis, nerve-sparing surgery remained statisticaly significant. CONCLUSIONS: The functional results in preserving cystectomy are promising. The preservation should be considered in young patients without erectile dysfunction.

La disfunción eréctil y su severidad están en relación con el número de factores de riesgo cardiovascular / Erectile Dysfunction and Its Severity Are Related to the Number of Cardiovascular Risk Factors

Objetivos: La disfunción eréctil (DE) es un estado muy común entre la población. Está en clara relación con la hipertensión arterial (HTA), la diabetes mellitus (DM), la dislipemia (DLP) y el síndrome metabólico (SM). El objetivo del presente estudio es esclarecer si la presencia y severidad de la DE están en relación con el número de factores de riesgo cardiovascular (FRCV). Material y métodos: Analizamos retrospectivamente las características de 242 varones derivados a nuestro centro para la realización de biopsia prostática entre septiembre de 2007 y diciembre de 2009. Se recogieron prospectivamente las siguientes variables: edad, altura, peso, índice de masa corporal (IMC), HTA, DM, DLP y obesidad (IMC < 30 kg/m2). Para describirla función eréctil utilizamos el cuestionario Erection Hardness Score. Analizamos la relación entre la presencia y severidad de DE y la presencia de HTA, DM, DLP y obesidad. Analizamos las variables clínicas en función de la presencia o ausencia de DE y en relación con su severidad. Resultados: La presencia de DE se relaciona con HTA (OR: 1,805 [1,128-2,887]; p = 0,013), DM (OR: 3,585 [1,613-7,966]; p = 0,001) y DLP (OR: 1,928 [1,062-3,500]; p = 0,029). La función eréctil no se relacionó con obesidad (OR: 0,929 [0,522-1,632]; p = 0,795). Los pacientes con DE eran más susceptibles de tener más FRCV (p = 0,009) y la severidad de la DE se encontró en relación con HTA (p < 0,001), DM (p < 0,001), DLP (p = 0,001) y el número FRCV (p < 0,001). Conclusiones: La presencia y severidad de la DE se encuentra en relación con la HTA, la DM, la DLP y el número de FRCV (AU)

Aim: Erectile dysfunction (ED) is a very common condition in the general population. ED isclosely related to Hypertension (HT), Diabetes Mellitus (DM), Dyslipidemia (DLP) and Metabolic Syndrome (MS). This study has aimed to clarify whether the presence and severity of ED are related to the presence and number of cardiovascular risk factors (CVRF). Material and methods: We retrospectively analyzed the characteristics of 242 males referred to our center for a prostate biopsy from September 2007 to December 2009. The following variables were collected prospectively: age, height, weight, body mass index (BMI), AHT, DM, DLP and obesity (BMI < 30 kg/m2). The Erection Hardness Score Questionnaire was used to assess erectile function. We analyzed the relation between the presence and severity of ED and the presence of HT, DM, DLP and obesity. We analyzed the clinical variables based on the presence or absence of ED and in relationship to its severity. Results: The presence of ED was related to HT (OR: 1.805 [1.128-2.887]; p = 0.013), DM (OR3.585 [1.613-7.966]; p = 0.001) and Dyslipidemia (OR: 1.928 [1.062-3.500]; p = 0.029). Erectile function was not related to Obesity (OR: 0.929 [0.522-1.632]; p = 0.795). Patients with ED were more likely to have more CVRF (p = 0.009) and the severity of ED was related to the presence of HT (p < 0.001), DM (p < 0.001), DLP (p = 0.001) and the number of CVRF (p < 0.001).Conclusions: The presence and severity of ED correlate with the presence of HT, DM, Dyslipidemia and the number of DVR (AU)

Hypertension, dyslipidemia and overweight are related to lower testosterone levels in a cohort of men undergoing prostate biopsy.

Testosterone deficiency syndrome (TDS) is a clinical and biochemical entity related to sexual and cardiovascular health. Hypertension, diabetes mellitus (DM), dyslipidemia and overweight are four clinical factors strongly related to cardiovascular illnesses. The aim of our study was to determine if the presence and number of cardiovascular risk factors was related to total testosterone levels and the presence of biochemical TDS. We retrospectively analyzed 384 patients referred to our center for prostate biopsy between September 2007 and December 2009. Variables age, height, weight, body mass index (BMI), tobacco use, alcohol intake, hypertension, DM, dyslipidemia (hypercholesterolemia/hypertriglyceridemia) and overweight (BMI>25) were recorded prospectively. Hormonal profile was determined as part of our clinical protocol. We used 231 and 346 ng dl(-1) as total testosterone cut-points (8-12 nmol l(-1)) for diagnosis of biochemical TDS, following ISA-ISSAM-EAU Guidelines. We analyzed the relationship between testosterone levels and the presence of hypertension, DM, dyslipidemia and overweight, and with the number of these cardiovascular risk factors. Mean age was 66 ± 8 years. Prevalence of TDS was 6.5% within the 231 ng ml(-1) cutoff point and 28.4% for the 346 ng dl(-1) cutoff point. Levels of testosterone were related to hypertension (P=0.007), dyslipidemia (P=0.013), overweight (P=0.036) and the number of cardiovascular risk factors (P=0.018). The prevalence of TDS in our population is comparable to data from international studies. Testosterone levels decrease as the number of cardiovascular risk factors rise.

[Erectile dysfunction and its severity are related to the number of cardiovascular risk factors]. / La disfunción eréctil y su severidad están en relación con el número de factores de riesgo cardiovascular.

AIM: Erectile dysfunction (ED) is a very common condition in the general population. ED is closely related to Hypertension (HT), Diabetes Mellitus (DM), Dyslipidemia (DLP) and Metabolic Syndrome (MS). This study has aimed to clarify whether the presence and severity of ED are related to the presence and number of cardiovascular risk factors (CVRF). MATERIAL AND METHODS: We retrospectively analyzed the characteristics of 242 males referred to our center for a prostate biopsy from September 2007 to December 2009. The following variables were collected prospectively: age, height, weight, body mass index (BMI), AHT, DM, DLP and obesity (BMI<30 kg/m(2)). The Erection Hardness Score Questionnaire was used to assess erectile function. We analyzed the relation between the presence and severity of ED and the presence of HT, DM, DLP and obesity. We analyzed the clinical variables based on the presence or absence of ED and in relationship to its severity. RESULTS: The presence of ED was related to HT (OR: 1.805 [1.128-2.887]; p=0.013), DM (OR 3.585 [1.613-7.966]; p=0.001) and Dyslipidemia (OR: 1.928 [1.062-3.500]; p=0.029). Erectile function was not related to Obesity (OR: 0.929 [0.522-1.632]; p=0.795). Patients with ED were more likely to have more CVRF (p=0.009) and the severity of ED was related to the presence of HT (p<0.001), DM (p<0.001), DLP (p=0.001) and the number of CVRF (p<0.001). CONCLUSIONS: The presence and severity of ED correlate with the presence of HT, DM, Dyslipidemia and the number of DVRF.

[New modes of ventilation: NAVA]. / Nuevos modos de ventilación: NAVA.

Neurally adjusted ventilatory assist (NAVA) is a new mode of assisted mechanical ventilation that uses the signal obtained from diaphragmatic electrical activity (Edi) to control the mechanical ventilator. Edi directly represents the central respiratory drive and reflects the length and intensity of the patient's neural effort. During NAVA, mechanical inspiratory assist starts when the respiratory center initiates the breath and is therefore independent of any pneumatic component. During inspiration, the pressure delivered is proportional to the Edi and the inspiratory pressure assist ceases when the neural activation of the diaphragm starts to decline after reaching the inspiratory maximum value. NAVA is a new conceptual approach to mechanical ventilation that can significantly improve patient-ventilator interaction and optimize the level of effective respiratory muscle unloading during assisted mechanical ventilation.

Nuevos modos de ventilación: NAVA / New modes of ventilation: NAVA

La ventilación asistida ajustada neuronalmente (NAVA) es un nuevo modo de ventilación mecánica asistida basado en la utilización de la señal obtenida de actividad eléctrica diafragmática (Edi) para el control del ventilador. La Edi representa directamente el impulso ventilatorio central y refleja la duración y la intensidad con que el paciente desea ventilar. Durante la NAVA la asistencia inspiratoria mecánica se inicia en el momento en que el centro respiratorio lo demanda, y el disparo es independiente de cualquier componente neumático. Durante la inspiración, la presión suministrada es proporcional a la Edi y la presurización inspiratoria cesa cuando la activación neural del diafragma comienza a disminuir tras alcanzar un valor máximo. Por sus características, el modo NAVA ofrece un nuevo enfoque conceptual a la ventilación mecánica que puede mejorar significativamente la interacción entre paciente y ventilador y puede optimizar la descarga muscular efectiva durante la ventilación asistida

Neurally adjusted ventilatory assist (NAVA) is anew mode of assisted mechanical ventilation thatuses the signal obtained from diaphragmaticelectrical activity (Edi) to control the mechanicalventilator. Edi directly represents the central respiratory drive and reflects the length and intensityof the patient’s neural effort. During NAVA, mechanicalinspiratory assist starts when the respiratorycenter initiates the breath and is thereforeindependent of any pneumatic component.During inspiration, the pressure delivered is proportional to the Edi and the inspiratory pressureassist ceases when the neural activation of the diaphragmstarts to decline after reaching the inspiratorymaximum value. NAVA is a new conceptualapproach to mechanical ventilation that cansignificantly improve patient-ventilator interactionand optimize the level of effective respiratorymuscle unloading during assisted mechanicalventilation

El infarto de miocardio en el diabético: implicaciones clínicas, pronósticas y terapéuticas en la era trombolítico-intervencionista / Myocardial infarction in diabetics: clinical, prognostic and therapeutic implications in the thrombolyticinterventionist era

Objetivo. El propósito de esta revisión es analizar la información generada en la actual era trombolítico-intervencionista con respecto a las implicaciones clínicas, pronósticas y terapeúticas del paciente diabético con infarto de miocardio. Fuente de datos. Búsqueda bibliográfica mediante la base de datos MEDLINE desde 1966 hasta 2000. Se usó metodología booleana usando los términos: infarto agudo de miocardio, diabetes mellitus, pronóstico, angioplastia coronaria transluminal percutánea y cirugía de injerto coronario. Por su relevancia se seleccionaron 88 estudios. Resultados. El aumento de la morbilidad y la mortalidad en el infarto del diabético se explica por el peor perfil basal de riesgo y por las mayores tasas de reinfarto y fallo cardíaco de estos pacientes. Los diabéticos con infarto se benefician particularmente de la administración de trombolíticos, bloqueadores beta, inhibidores de la enzima conversiva de la angiotensina y de un estricto control glucometabólico. Debido a la afectación más difusa de los vasos coronarios y a la aterogénesis más acelerada, los diabéticos presentan peores resultados con las técnicas de revascularización que los no diabéticos. Aunque no está definitivamente establecido, en diabéticos con afectación multivaso la revascularización quirúrgica ha demostrado ser superior a la percutánea. El papel del stent y de los antagonistas de las glucoproteínas plaquetarias IIb/IIIa para optimizar los resultados de la angioplastia en el diabético, aunque prometedor, está pendiente de confirmación. Conclusión. Los diabéticos que sufren un infarto de miocardio deben ser considerados per se como de alto riesgo y, por esta misma razón, se benefician más que los no diabéticos de las modernas intervenciones farmacológicas y revascularizadoras. En el momento actual, están en marcha estudios aleatorizados que permitirán definir en los próximos años cuál será la estrategia de revascularización y la medicación coadyuvante más efectiva en estos pacientes (AU)

Short-term effects of inhaled nitric oxide and prone position in pulmonary and extrapulmonary acute respiratory distress syndrome.

Inhaled nitric oxide (NO) and prone position (PP) are frequently used in the treatment of acute respiratory distress syndrome (ARDS). We compared the gas exchange and hemodynamic effects induced by the combination of NO inhalation and PP in patients with ARDS and analyzed whether or not pulmonary (Pu) and extrapulmonary (Epu) ARDS patients behave differently. Eight Pu and seven Epu ARDS patients were studied in four situations: supine position (SP); SP with NO inhalation at 5 ppm (SP + NO); PP; and PP with NO inhalation (PP + NO). In comparison with SP, NO inhalation and PP induced significant increases in Pa(O(2))/FI(O(2)) (from 106 +/- 58 in SP to 131 +/- 69 mm Hg in SP + NO, p = 0.01, and to 184 +/- 67 mm Hg in PP, p < 0.001). Pu and Epu ARDS showed a similar improvement in Pa(O(2))/FI(O2) with PP. Only Pu ARDS patients showed a significant increase (p < 0.001) in oxygenation induced by NO inhalation from 81 +/- 45 to 100 +/- 50 mm Hg in SP, and from 146 +/- 53 to 197 +/- 98 mm Hg in PP. In conclusion, PP is associated with a marked improvement in oxygenation, irrespective of the causes of ARDS, and additive effects of NO inhalation are mainly seen in patients with Pu ARDS.

[Cranioencephalic trauma in adults: clinical and radiologic features]. / Traumatismo craneoencefálico del adulto: aspectos clínicos y radiológicos.

BACKGROUND: To analyse extracranial complications and basic variables in head-injury patients, such as Glasgow coma score (GCS), intracranial pressure (ICP) and cranial computerized tomography (CT), in relation to the outcome of these patients. PATIENTS AND METHODS: 64 consecutive patients (47 males and 17 females) with head injury, admitted from January 1992 to May 1994, were studied in this prospective study. Mean age was 37 +/- 18 years. Overall mortality was 23% (15/64). Student-t and Chi-square tests were used for statistical analysis, and p < 0.05 was considered statistical significant. RESULTS: Overall GCS was 7 +/- 3, survivors presenting GCS of 7.7 +/- 2.9 and non-survivors 4.7 +/- 1.5 (p = 0.04). CT were classified as follows: diffuse injury, 4 patients (7%); focal injury, 32 (53%), and mixed injury 24 (40%). Depending on the presence or absence of mesencephalic cisterns in the CT, GSC was 7.6 +/- 2.8 and 4.3 +/- 1.4, respectively (p = 0.04). Subarachnoid hemorrhage (SAH) was associated to a GCS of 6.3 +/- 2.5 and its absence to 8 +/- 3.3 (p = 0.03). The absence of mesencephalic cisterns and SAH were more frequent in the non-survivors, 72% and 32% (p = 0.01 and 0.04), respectively. ICP was recorded in 42 patients. Regarding to ICP, mortality was: 6.7% with ICP < or = 20 mmHg, 37% with ICP 21-30, 44% with ICP 31-40 and 67% with ICP > 50 mmHg (p = 0.03). Diabetes insipidus, cardiorespiratory arrest, shock, prolonged mechanical ventilation, SDRA and sepsis were the most frequent extracranial complications in non-survivors. CONCLUSIONS: There is an association between the outcome of head-injury patients with the GCS and ICP values. Absence of mesencephalic cisterns and SAH were radiologic signs of poor prognosis. Patients who died had more extracranial complications.

Prognostic indexes and mortality in critically ill patients with acute renal failure treated with different dialytic techniques.

The objective of this study was to compare the evolution of patients with acute renal failure (ARF) treated conservatively or with different dialytic techniques in an intensive care unit (ICU). From June 1992 to November 1994, 1087 consecutive patients were admitted in our ICU. Two hundred and twenty of these presented with ARF, and were divided into three groups; group I (control group): 156 patients with ARF who did not receive substitutive techniques; group II: 21 patients under intermittent hemodialysis (IHD) or peritoneal dialysis (PD); group III: 43 patients under continuous hemodiafiltration (CHDF). The studied variables were age, etiology of renal failure, requirement of dialysis, type of dialysis, length of ICU and hospital stay, and renal function outcome. APACHE II and SAPS scores were recorded on admission and analyzed for hospital mortality. Chi-square test and the analysis of variance were used for the statistical analysis. Results are presented as mean +/- SD. A p value below 0.05 was considered statistically significant. Although etiology of ARF was multifactorial, we found a high frequency of ARF due to sepsis (56.8%), hypoperfusion (58.7%), and acute tubular necrosis (62.5%). Sepsis and heart failure were clinical conditions associated to a greater mortality. We did not find any statistical difference between the two dialyzed groups for all the studied variables, nor between the three groups regarding APACHE II and hospital stay. Significant differences were found between dialyzed and non-dialyzed patients respect to age, group I: 64.1 +/- 13.6, group II: 56.4 +/- 19.7, and group III: 56.0 +/- 14.1 (p < 0.001), creatinine peak serum levels, group I: 260 +/- 130, group II: 494 +/- 209, and group III: 441 +/- 170 mumol/L (p < 0.0001), and mortality, group I: 46.9%, group II: 66.7%, and group III: 76.2% (p < 0.002). SAPS score showed differences between the control group and the CHDF group 13.9 +/- 4.8 and 16.4 +/- 5.4 (p < 0.007), respectively. The use of dialytic techniques in critically ill ARF patients is associated with greater mortality. Prognostic indexes on admission did not correctly classify our patients with ARF. Continuous hemodiafiltration does not involve greater mortality or length of stay as compared to conventional dialysis.