Predictores de éxito del tratamiento con cánula nasal de alto flujo en el fallo respiratorio agudo hipoxémico / Predictors of success of high-flow nasal cannula in the treatment of acute hypoxemic respiratory failure

Introducción: La terapia con cánula nasal de alto flujo (CNAF) se ha introducido recientemente en el tratamiento del fallo respiratorio agudo (FRA), siendo una técnica segura, confortable y eficaz que logra revertir la hipoxemia en estos pacientes. Es necesario disponer de herramientas que nos permitan detectar precozmente el fallo de este tipo de tratamiento para evitar el incremento de la mortalidad que puede conllevar. El objetivo primario de este estudio ha sido analizar el impacto que la frecuencia respiratoria (FR), la saturación periférica de oxígeno (SpO2), la fracción inspirada de oxígeno (FiO2) y el índice ROX (IROX=[SpO2/FiO2]/FR) tienen sobre el éxito de la CNAF en los pacientes con FRA hipoxémico. Los objetivos secundarios han sido analizar la estancia y la mortalidad en la UCI y la necesidad de ventilación mecánica (VM). Material y métodos Se trata de un estudio retrospectivo efectuado en una UCI polivalente del Hospital Comarcal de Montilla (Córdoba). Se incluyeron los pacientes tratados con CNAF por FRA hipoxémico desde enero de 2016 hasta enero de 2018.ResultadosDesde enero de 2016 hasta enero de 2018 se trataron 27 pacientes con FRA, de los cuales 19 (70,37%) presentaban FRA hipoxémico. De estos, 15 (78,95%) respondieron bien al tratamiento y 4 (21,05%) fracasaron. A las 2h de tratamiento la FR demostró ser el mejor predictor (área bajo la curva ROC [AUROC] 0,858; IC95%: 0,63-1,05; p=0,035). La FiO2 y el IROX fueron buenos predictores a las 8h de tratamiento (FiO2: AUROC 0,95; IC95%: 0,85-1,04; p=0,007, e IROX: AUROC 0,967; IC95%: 0,886-1,047; p=0,005). El mejor punto de corte de la FR a la segunda hora fue de 29 respiraciones/min (sensibilidad 75%, especificidad 87%). El mejor punto de corte de la FiO2 a las 8h de tratamiento fue de 0,59 (75% sensibilidad, 93% especificidad). El mejor punto de corte para IROX a las 8h de tratamiento fue de 5,98 (sensibilidad 100%, especificidad 75%). ... (AU)

Background: High-flow nasal cannula (HFNC) therapy is used in the treatment of acute respiratory failure (ARF) and is both safe and effective in reversing hypoxemia. In order to minimize mortality and clinical complications associated to this practice, a series of tools must be developed to allow early detection of failure. The present study was carried out to: (i)examine the impact of respiratory rate (RR), peripheral oxygen saturation (SpO2), ROX index (ROXI=[SpO2/FiO2]/RR) and oxygen inspired fraction (FiO2) on the success of HFNC in patients with hypoxemic ARF; and (ii)analyze the length of stay and mortality in the ICU, and the need for mechanical ventilation (MV).MethodsA retrospective study was carried out in the medical-surgical ICU of Hospital de Montilla (Córdoba, Spain). Patients diagnosed with hypoxemic ARF and treated with HFNC from January 2016 to January 2018 were included.ResultsOut of 27 patients diagnosed with ARF, 19 (70.37%) had hypoxemic ARF. Fifteen of them (78.95%) responded satisfactorily to HFNC, while four (21.05%) failed. After two hours of treatment, RR proved to be the best predictor of success (area under the ROC curve [AUROC] 0.858; 95%CI: 0.63-1.05; P=.035). For this parameter, the optimal cutoff point was 29rpm (sensitivity 75%, specificity 87%). After 8hours of treatment, FiO2 and ROXI were reliable predictors of success (FiO2: AUROC 0.95; 95%CI: 0.85-1.04; P=.007 and ROXI: AUROC 0.967; 95%CI: 0.886-1.047; P=.005). In the case of FiO2 the optimal cutoff point was 0.59 (sensitivity 75%, specificity 93%), while the best cutoff point for ROXI was 5.98 (sensitivity 100%, specificity 75%). Using a Cox regression model, we found RR<29rpm after two hours of treatment, and FiO2<0.59 and ROXI>5.98 after 8hours of treatment, to be associated with a lesser risk of MV (RR: HR 0.103; 95%CI: 0.11-0.99; P=.05; FiO2: HR 0.053; 95%CI: 0.005-0.52; P=.012; and ROXI: HR 0.077; 95%CI: 0.008-0.755; P=.028, respectively). ... (AU)

Predictors of success of high-flow nasal cannula in the treatment of acute hypoxemic respiratory failure. / Predictores de éxito del tratamiento con cánula nasal de alto flujo en el fallo respiratorio agudo hipoxémico.

BACKGROUND: High-flow nasal cannula (HFNC) therapy is used in the treatment of acute respiratory failure (ARF) and is both safe and effective in reversing hypoxemia. In order to minimize mortality and clinical complications associated to this practice, a series of tools must be developed to allow early detection of failure. The present study was carried out to: (i)examine the impact of respiratory rate (RR), peripheral oxygen saturation (SpO2), ROX index (ROXI=[SpO2/FiO2]/RR) and oxygen inspired fraction (FiO2) on the success of HFNC in patients with hypoxemic ARF; and (ii)analyze the length of stay and mortality in the ICU, and the need for mechanical ventilation (MV). METHODS: A retrospective study was carried out in the medical-surgical ICU of Hospital de Montilla (Córdoba, Spain). Patients diagnosed with hypoxemic ARF and treated with HFNC from January 2016 to January 2018 were included. RESULTS: Out of 27 patients diagnosed with ARF, 19 (70.37%) had hypoxemic ARF. Fifteen of them (78.95%) responded satisfactorily to HFNC, while four (21.05%) failed. After two hours of treatment, RR proved to be the best predictor of success (area under the ROC curve [AUROC] 0.858; 95%CI: 0.63-1.05; P=.035). For this parameter, the optimal cutoff point was 29rpm (sensitivity 75%, specificity 87%). After 8hours of treatment, FiO2 and ROXI were reliable predictors of success (FiO2: AUROC 0.95; 95%CI: 0.85-1.04; P=.007 and ROXI: AUROC 0.967; 95%CI: 0.886-1.047; P=.005). In the case of FiO2 the optimal cutoff point was 0.59 (sensitivity 75%, specificity 93%), while the best cutoff point for ROXI was 5.98 (sensitivity 100%, specificity 75%). Using a Cox regression model, we found RR<29rpm after two hours of treatment, and FiO2<0.59 and ROXI>5.98 after 8hours of treatment, to be associated with a lesser risk of MV (RR: HR 0.103; 95%CI: 0.11-0.99; P=.05; FiO2: HR 0.053; 95%CI: 0.005-0.52; P=.012; and ROXI: HR 0.077; 95%CI: 0.008-0.755; P=.028, respectively). CONCLUSIONS: RR after two hours of treatment, and FiO2 and ROXI after 8hours of treatment, were the best predictors of success of HFNC. RR<29rpm, FiO2<0.59 and ROXI>5.98 were associated with a lesser risk of MV.

Nódulos "arrosariados" en antebrazos / Beaded Nodules on the Forearms

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Ambrosio Paré. Aportaciones a la cirugía / Ambroise Paré. Contributions to surgery

A Ambrosio Paré se le considera por muchos el padre de la cirugía moderna. Sin estudios académicos y actuando como barberocirujano participó en numerosas guerras, lo que le permitió adquirir amplios conocimientos y experiencia en el tratamiento de las heridas. Por otro lado llego a ser el cirujano y medico de cámara de nobles y de cuatro Reyes de Francia. Realizó múltiples aportaciones en numerosos campos del conocimiento sobre diversos temas, destacando el tratamiento de las heridas y amputaciones, realizando aportaciones en el diseño de material quirúrgico y prótesis de extremidades. En el campo vascular se podría destacar la sugerencia de la etiología de los aneurismas por la sífilis, la hemostasia de los vasos sanguíneos, la ligadura de los vasos en las amputaciones y el diseño de pinzas para la prensión de los conductos vasculares. Su obra ha quedado plasmada en numerosos documentos, en especial libros que ha servido para la trasmisión de sus aportaciones durante décadas y más bien siglos

Ambroise Paré is considered by many the father of modern surgery. Without academic studies and acting as a barber-surgeon he participated in numerous wars, which allowed him to acquire extensive knowledge and experience in the treatment of wounds. On the other hand he became the surgeon and chamber doctor of nobles and four Kings of France. He made multiple contributions in numerous fields of knowledge on various topics, highlighting the treatment of wounds and amputations, made contributions with the design of surgical material and limb prostheses. In the vascular field, the suggestion of the etiology of aneurysms due to syphilis, the hemostasis of blood vessels, the ligation of vessels in amputations and the design of forceps for blood vessel grasping could be highlighted. His work has been reflected in numerous documents, especially books that have served to transmit their contributions for decades and centuries

Factors associated with seminal impairment in HIV-infected men under antiretroviral therapy.

STUDY QUESTION: How do semen parameters of HIV-infected men under antiretroviral treatment compare with WHO parameters of normal semen, and what factors are associated with any differences? SUMMARY ANSWER: Semen quality in most HIV-infected patients under antiretroviral treatment exceeds WHO limits, but the number falling below them is higher than would be expected in a healthy population. Exposure to efavirenz has a significant association with dysmotility. WHAT IS KNOWN ALREADY: Dysmotility is the most frequently described sperm alteration related to HIV infection, and it has recently been linked to treatment with non-nucleoside reverse transcriptase inhibitors, particularly to efavirenz. STUDY DESIGN, SIZE, DURATION: Prospective cohort study. Between March 2002 and December 2013, 139 HIV-infected men undergoing antiretroviral therapy were enrolled. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were male members of serodiscordant couples who attended a clinic for sexually transmitted infections (STIs) in Madrid and requested reproductive counselling. Sociodemographic, behavioural and clinical data were collected. CD4+ lymphocyte count, HIV viral load, serology/viral load of hepatitis B and C viruses, syphilis serology and other STIs diagnosis were performed. Semen parameters were assessed through standard sperm analysis and were compared with WHO 2010 reference values. Factors associated with impaired semen parameters were evaluated by bivariate and multivariate analysis. MAIN RESULTS AND THE ROLE OF CHANCE: The median values of all assessed semen parameters were within a normal range, but in up to 19% of HIV-positive males, at least one parameter of semen quality was below the normal range. A significant association between treatment with efavirenz and the presence of dysmotility was detected in the multivariate analysis. LIMITATIONS, REASONS FOR CAUTION: Our results cannot demonstrate a causal relationship between exposure to efavirenz and impaired motility. We do not have a real comparison group as the WHO cohort is international and may not reflect local variations in semen characteristics. Subjects who requested reproductive counselling might not be representative of HIV-positive men in general. WIDER IMPLICATIONS OF THE FINDINGS: Since efavirenz is still widely used in current therapeutic regimens may be affecting fertility in seropositive men who desire procreation. STUDY FUNDING/COMPETING INTERESTS: No external funding was used for this study. The authors have no conflict of interest to declare.

Estudio descriptivo de los factores de contaminación en las tomas forenses de muestras de ADN / Descriptive study of the causes of contamination in forensic sampling of DNA

La contaminación de las muestras de ADN en el ámbito judicial tiene una enorme trascendencia en todos los procesos, especialmente en los penales. Con el objetivo de conocer los factores que condicionan esta contaminación, así como el grado de la misma, hemos diseñado un trabajo experimental que incluye cuatro equipos diferentes, cada uno de los cuales realiza de tres maneras diferentes la toma (correcta, incorrecta y muy incorrecta). Los resultados del estudio muestran una mínima contaminación por manipulación incorrecta, así como por contaminación residual en las instalaciones de trabajo. Se concluye que aunque los métodos habituales de toma de muestras son seguros, es conveniente siempre asegurarse de que se cumplen los protocolos de toma de muestras y de limpieza de las instalaciones de trabajo (AU)

The contamination of DNA samples in forensic context is very important in all kind of trials, specially in penal trials. With the goal to know factors which produce this contamination and degree of its, we are designed an experimental study with four forensic experts and three ways to make this samples collection (correct, incorrect and very incorrect). Results of this study show a minimum contamination in handling and residual contamination too in workplaces. We conclude that although the routine methodology in sample collection could be consider reliable; furthermore it's necessary achieve protocols of samples collection and cleanliness of workplaces (AU)

Traumatismos Vasculares del miembro superior / Upper-Extremity vascualr injuries

Los traumatismos de los vasos del miembro superior, en nuestro medio no es una patología muy frecuente. Sin embargo lesiones fundamentalmente iatrogénicas provocadas por los abordajes vasculares de los vasos fundamentalmente para las técnicas de monitorización de los procedimientos terapéuticos o técnicas que precisan este tipo de acceso y muy especialmente para el tratamiento de la patología coronaria, junto con otros traumatismos relacionados con los accidentes de tráficos, laborales y domésticos ha hecho que la incidencia se haya incrementado, aumentando la relevancia de este tipo de afecciones. Se analizan en el trabajo como revisión, aspectos muy variados, que van desde la etiología, etiopatogénica, clínica, diagnostico y las modalidades del tratamiento (AU)

Trauma to the vessels of the upper limb in our environment is not a very common disease. However iatrogenic injuries mainly by vascular vessel approaches techniques primarily for monitoring of therapeutic procedures or techniques that require such access and especially for the treatment of coronary disease, together with other related injuries, accidents of traffic, and domestic labor has made the incidence has increased, increasing the relevance of these types of conditions. Are analyzed at work and revision varied aspects, ranging from the etiology, etiopathogenic, clinical, diagnostic and treatment modalities (AU)

Dermatitis shiitake / Shiitake dermatitis

La dermatitis por shiitake fue descrita por primera vez en 1977 en Japón por Nakamura, y se desarrolla tras la ingesta de setas shiitake poco cocinadas o crudas en determinadas personas. Esta dermatitis es muy característica por la presencia de pápulas, placas o vesículas muy pruriginosas diseminadas que adoptan una disposición lineal o flagelada. Presentamos un varón de 38 años, remitido por erupción pruriginosa de 3 días de evolución, tras el interrogatorio reconoció haber comido unas se tasen un restaurante chino (AU)

Shiitake dermatitis was first described in 1977 in Japan by Nakamura and takes place after the intake of little cooked or raw shiitake mushrooms in certain persons. This condition is very characteristic for the presence of papules, plaques or vesicles, scattered highly pruritic that adopt a linear or flagellate disposal. We present a man of 38 years, submitted by pruritic eruption of 3 days duration, after questioning admitted some mushrooms eaten in a Chinese restaurant (AU)

Nódulo centrofacial de reciente aparición / A Midfacial Nodule of Recent Onset

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Breastfeeding initiation in immigrant and non-immigrant women in Spain.

Research about inequities between native and immigrant women regarding the quality of health care is still scarce. Initiation of breastfeeding in hospital is considered a quality care indicator. In this study, we explore the association between the geographical origin of the women and the establishment of breastfeeding in Spanish hospitals. Prevalence of breastfeeding initiation is higher for women from Latin America, Eastern Europe, Maghreb or sub-Saharan Africa than for Spanish women, and lower for Chinese women. Compared with Spanish women the odds of not breastfeeding in hospital were lower in all these immigrant groups but more than five times higher for Chinese immigrants. Culturally adapted health services are necessary to maintain breastfeeding rates in most immigrant groups. Moreover, it seems urgent to identify the factors influencing patterns of breastfeeding in Chinese immigrants and to develop innovative strategies to encourage breastfeeding initiation in hospital.

[Leishmaniasis and rheumatoid nodulosis in a patient with HIV infection]. / Leishmaniasis y nodulosis reumatoide en paciente con infección por el virus de la inmunodeficiencia humana.

We describe the case of a 44-year-old homosexual man diagnosed with HIV infection and visceral leishmaniasis. He presented nodules on the dorsum of the hands. Histological study of one of the nodules revealed necrobiotic palisading granulomas with abundant Leishmania amastigotes within the histiocytes and in the adjacent extracellular space. Tissue and peripheral blood cultures were positive for Leishmania infantum, zymodeme MON-24. A biopsy of healthy skin did not reveal the presence of Leishmania. A diagnosis of rheumatoid nodulosis with Leishmania was made and treatment was started with intravenous liposomal amphotericin, leading to slight improvement. We believe that the presence of the parasite within the nodules was the result of its dissemination during visceral leishmaniasis in an immunocompromised patient with HIV infection, and that the Leishmania did not have an etiological role in the appearance of the nodules. We present the first case of the association between Leishmania and rheumatoid nodulosis.

Leishmaniasis y nodulosis reumatoide en paciente con infección por el virus de la inmunodeficiencia humana / Leishmaniasis and rheumatoid nodulosis in a patient with HIV infection

Describimos el caso de un paciente varón de 44 años, homosexual, infectado por el virus de la inmunodeficiencia humana (VIH) y diagnosticado de leishmaniasis visceral. Clínicamente presentaba unos nódulos en el dorso de las manos. El estudio histológico de uno de ellos mostraba granulomas necrobióticos en empalizada y abundantes amastigotes de Leishmania dentro de los histiocitos y extracelularmente en la proximidad. Los cultivos tisulares y de sangre periférica fueron positivos para Leishmania infantum, con el análisis isoenzimático zymodema 24. Una biopsia de piel sana no reveló la presencia de Leishmania. El diagnóstico fue de nodulosis reumatoide con Leishmania, y se inició tratamiento con anfotericina liposomal intravenosa con leve mejoría. Consideramos que la presencia del parásito en los nódulos fue producida por la diseminación durante la leishmaniasis visceral, en el contexto de un paciente inmunosuprimido, como en una infección por el VIH, y no tiene un papel etiológico en su origen. Es decir, no pensamos que los parásitos hayan producido los nódulos. Presentamos el primer caso de asociación entre leishmania y nodulosis reumatoide (AU)

We describe the case of a 44-year-old homosexual man diagnosed with HIV infection and visceral leishmaniasis. He presented nodules on the dorsum of the hands. Histological study of one of the nodules revealed necrobiotic palisading granulomas with abundant Leishmania amastigotes within the histiocytes and in the adjacent extracellular space. Tissue and peripheral blood cultures were positive for Leishmania infantum, zymodeme MON-24. A biopsy of healthy skin did not reveal the presence of Leishmania. A diagnosis of rheumatoid nodulosis with Leishmania was made and treatment was started with intravenous liposomal amphotericin, leading to slight improvement. We believe that the presence of the parasite within the nodules was the result of its dissemination during visceral leishmaniasis in an immunocompromised patient with HIV infection, and that the Leishmania did not have an etiological role in the appearance of the nodules. We present the first case of the association between Leishmania and rheumatoid nodulosis (AU)

Tumor del cuerpo carotídeo en paciente joven / Carotid body tumour in young patient

Se presenta por los autores un caso de tumor carotídeo desarrollado en una joven. Se realiza una revisión sobre el manejo de este tipo de patología y se discute las características del caso con la información disponible en la bibliografía

The authors present a case of Carotid body tumor in a young women. A review of carotid body tumour management is made and have the discussion with the characteristics of the case in comparition of the information of the bibliography

Carcinoma verrugoso facial. Descripción de dos casos / Verrucous Carcinoma of the Face: A Report of 2 Cases

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Costo de estadía en Cuidados Paliativos especializados y servicios convencionales / No disponible

Introducción: en la mayoría de los países la financiación de los servicios de Cuidados Paliativos es mixta y se combinan ayudas de caridad con fondos privados y estatales. La Clínica Familia, hospicio especializado en cuidados paliativos, tiene un 50% del costo real subsidiado por profesionales voluntarios y servicios al costo, el otro 50% proviene del Estado y de privados. Este centro, entre otros, cubre una parte de la demanda de los cuidados paliativos hospitalizados, existiendo enfermos que no reciben cuidados paliativos especializados. Objetivo: con el objetivo de analizar el costo de estadía en cuidados paliativos, se realizó un estudio descriptivo en tres centros de salud que acogen enfermos terminales: un centro especializado en cuidados paliativos y dos servicios convencionales: un hospital público y un hospital universitario, en el segundo semestre del año 2005. Material y métodos: para ello se calculó el costo de estadía a través dela siguiente fórmula: 1/30 x (GMF/DC + GMV/O), y se evaluó un costo aproximado en dólares de cuatro indicadores: control de síntomas, apoyo emocional, apoyo espiritual y educación a la familia, en los tres servicios estudiados. Resultados y conclusiones: se observa un menor costo de estadía en el servicio especializado de cuidados paliativos y variaciones en indicadores de resultados, que lo hace recomendable en relación a los servicios convencionales. Esto podría tener un menor costo de estadía, mayor cobertura y más beneficios para el paciente y su familia (AU)

Background: most countries have mixed funding for palliative care services, with a combination of charity, private, and governmental funds. Clínica Familia, a hospice specializing in palliative care, has 50% of total costs funded by professional volunteers and at-cost services, with the remaining 50% deriving from private and public sources. This center, among others, partly covers the demand for in-hospital palliative care, and so some patients do not receive such specialized palliative care. Objective: with the goal of analyzing cost of stay in palliative care a descriptive study was performed in three health centers admitting terminally ill patients: a center specialized in palliative care and two conventional sites –a public hospital and a university hospital– in the second semester of 2005. Material and methods: cost of stay was estimated using the following formula: 1/30 x (FME/BA + VME/O) (FME: fixed monthly expenses; BA: bed availability; VME: variable monthly expenses; O: bed occupation), and the approximate cost of four markers -symptom control, emotional support, spiritual support, and family education- was calculated in dollars in the three sites involved. Results and conclusions: a lower cost of stay was seen in the site specialized in palliative care, as well as variation in outcome markers, which makes this option preferrable to conventional services. This option might offer lower costs of stay, greater coverage, and more benefits for patients and their families (AU)