Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study.

Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either "early" (within 14 d of intubation) or "late" (more than 14 d after intubation). DESIGN: International multi-institute retrospective cohort study. SETTING: Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. PATIENTS: Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p < 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified. CONCLUSIONS: COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

Of rats and people: a select comparative analysis of cue competition, the contents of learning, and retrieval

Select literature regarding cue competition, the contents of learning, and retrieval processes is summarized to demonstrate parallels and differences between human and nonhuman associative learning. Competition phenomena such as blocking, overshadowing, and relative predictive validity are largely analogous in animal and human learning. In general, strong parallels are found in the associative structures established during learning, as well as in the basic phenomena associated with information retrieval. Some differences arise too, such as retrospective evaluation, which seems easier to observe in human than in nonhuman animals. However, the parallels are sufficient to indicate that the study of learning in animals continues to be relevant to human learning and memory (AU)

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Implementación de un sistema de alarmas automático para la detección precoz de los pacientes con sepsis grave / Implementation of an automatic alarms system for early detection of patients with severe sepsis

OBJETIVO: Valorar la utilidad de una herramienta informática integrada en el programa de historia clínica de urgencias en el momento del triaje, para detectar de forma precoz pacientes con sepsis grave, y su posible repercusión en reducir las cifras de mortalidad en los pacientes atendidos. MÉTODO: El estudio constaba de 2 muestras comparativas. La selección de pacientes se realizó de forma retrospectiva en los 2 grupos utilizando los códigos CIE-9 al alta de urgencias y hospitalaria 038.9, 995.91 para la sepsis, 995.92 para sepsis grave y 785.52 para shock séptico. La muestra denominada «alarmas» constaba de los pacientes estudiados tras implantar el sistema de alarmas de sepsis en el sistema informático de urgencias. Se definieron 2 tipos de alarmas, una de gravedad y otra de alerta en función de las constantes vitales alteradas. La muestra histórica, denominada «sin alarmas», constaba de pacientes atendidos en el servicio de urgencias durante el año previo a la implantación del sistema de alarmas. RESULTADOS: El porcentaje de cumplimiento del paquete de tratamiento de la sepsis fue mayor en la muestra de alarmas, comparativamente con la muestra sin alarmas, respectivamente, para los hemocultivos 96,3% frente a 80,9% (p < 0,001), antibiótico menor a 1 h 62,9% frente a 39,3% (p < 0,001), determinación de ácido láctico 91,4% frente a 77,9% (p < 0,001) y la aplicación de volumen adecuado 57,7% frente a 54,3% (p = 0,54). La mortalidad durante el ingreso se redujo en términos absolutos del 25% de la muestra sin alarmas al 13,6% en la muestra con alarmas. La supervivencia a los 30 días fue mayor en la muestra de alarmas (log rank = 0,004). CONCLUSIONES: Un sistema electrónico de identificación de pacientes con sepsis permite una mayor precocidad en la actuación, un cumplimiento mejor de las medidas básicas y por tanto una disminución de la estancia y la mortalidad

OBJECTIVE: The objective of this study was to assess the usefulness of a software tool integrated into the medical electronic history at the time of emergency triage. The aim was the early detection of patients with severe sepsis, and the potential impact of this software tool on reducing the mortality rate in patients treated. METHOD: The study consisted of two comparative samples. Patient selection was performed retrospectively into two groups using ICD-9 codes from the hospital and emergency department discharge reports. The codes were 038.9, 995.9 and 995.92 for sepsis, and 785.52 for severe sepsis and septic shock. The sample called «alarms» consisted of patients studied after implementing the sepsis alarm system in the Emergency Department computer system. There were two types of alarms, a serious one and an alert one depending on the on vital signs defined. The historical sample called «no alarms» consisted of patients seen in the Emergency Department during the year before the introduction of the alarm system. RESULTS: The compliance rate of the sepsis treatment package was higher in the «alarms» sample, compared to the sample without alarms, with blood cultures, 96.3% versus 80.9% (P < .001), antibiotic treatment in less than one hour, 62.9% vs. 39.3% (P < .001), determination of lactic acid, 91.4% vs. 77.9% (P < .001), and applying appropriate volume, 57.7% vs 54.3% (P = .052), respectively. The hospital mortality was reduced in absolute terms from 25% in the sample without alarms to 13.6% in the sample with alarms. Survival at 30 days was higher in the sample with alarms (Log Rank = .004). CONCLUSIONS: There were no studies that evaluated the effectiveness of an alarm system in our literature search. An electronic identification system for patients with sepsis allows acting earlier, better compliance with basic measures, and a reduction in hospital stay and mortality

[Implementation of an automatic alarms system for early detection of patients with severe sepsis]. / Implementación de un sistema de alarmas automático para la detección precoz de los pacientes con sepsis grave.

OBJECTIVE: The objective of this study was to assess the usefulness of a software tool integrated into the medical electronic history at the time of emergency triage. The aim was the early detection of patients with severe sepsis, and the potential impact of this software tool on reducing the mortality rate in patients treated. METHOD: The study consisted of two comparative samples. Patient selection was performed retrospectively into two groups using ICD-9 codes from the hospital and emergency department discharge reports. The codes were 038.9, 995.9 and 995.92 for sepsis, and 785.52 for severe sepsis and septic shock. The sample called «alarms¼ consisted of patients studied after implementing the sepsis alarm system in the Emergency Department computer system. There were two types of alarms, a serious one and an alert one depending on the on vital signs defined. The historical sample called «no alarms¼ consisted of patients seen in the Emergency Department during the year before the introduction of the alarm system. RESULTS: The compliance rate of the sepsis treatment package was higher in the «alarms¼ sample, compared to the sample without alarms, with blood cultures, 96.3% versus 80.9% (P<.001), antibiotic treatment in less than one hour, 62.9% vs. 39.3% (P<.001), determination of lactic acid, 91.4% vs. 77.9% (P<.001), and applying appropriate volume, 57.7% vs 54.3% (P=.052), respectively. The hospital mortality was reduced in absolute terms from 25% in the sample without alarms to 13.6% in the sample with alarms. Survival at 30 days was higher in the sample with alarms (Log Rank=.004). CONCLUSIONS: There were no studies that evaluated the effectiveness of an alarm system in our literature search. An electronic identification system for patients with sepsis allows acting earlier, better compliance with basic measures, and a reduction in hospital stay and mortality.

Caracterización de cepas de Staphylococcus epidermidis y S. haemolyticus resistentes a meticilina y linezolid en un hospital español / Characterization of methicillin- and linezolid-resistant Staphylococcus epidermidis and S. haemolyticus strains in a Spanish hospital

La resistencia a linezolid se produce generalmente por mutaciones en el ARNr 23S. El objetivo de este estudio fue caracterizar cepas de Staphylococcus epidermidis (SE) y S. haemolyticus (SH) resistentes a linezolid y meticilina (SE-LMR y SH-LMR, respectivamente) detectadas en un hospital español. Métodos Se estudiaron todas las cepas SE-LMR y SH-LMR aisladas en el periodo de junio 2009 a agosto 2011, en un hospital de segundo nivel, así como las características epidemiológicas de los pacientes. Se tiparon las cepas (25 SE-LMR y 2 SH-LMR, procedentes de 20 pacientes) y se determinó su fenotipo y genotipo de resistencia y la presencia de genes de virulencia. Resultados En todas las cepas analizadas se detectó la mutación G2603T en el ARNr 23S y también cambios aminoacídicos en las proteínas ribosomales L3 y L4. Las 25 cepas SE-LMR pertenecieron a la secuencia tipo ST2, su SCCmec fue el tipo III y presentaron 2 patrones diferentes de PFGE. El SCCmec de las 2 cepas SH-LMR fue no tipable. Las cepas SE-LMR contenían los genes de resistencia aac(6’)-aph(2”) y dfrS1, y las cepas SH-LMR poseían además el gen erm(C). No se detectaron genes de resistencia a lincomicina en las cepas SE-LMR a pesar de mostrar sensibilidad disminuida a clindamicina y resistencia a lincomicina. Conclusiones La resistencia a linezolid en el ámbito hospitalario es preocupante y requiere una continua vigilancia. Esta resistencia se asoció a la mutación G2603T en el ARNr 23S y a la presencia de cambios aminoacídicos en L3 y/o L4 (AU)

Introduction Linezolid resistance is mainly due to mutations in the 23S rRNA target. The aim of this study was to characterize linezolid and methicillin resistant Staphylococcus epidermidis (SE-LMR) and S. haemolyticus (SH-LMR) strains detected in a Spanish hospital. Methods SE-LMR and SH-LMR strains obtained in the period June 2009-August 2011 in a second level hospital were recorded along with the epidemiological characteristics of the patients. These strains were typed, and their resistance, phenotype, genotype and the factors determining their virulence were analysed. Results Linezolid resistance was explained by the presence of G2603T mutation (23S rRNA) and aminoacid changes in L3 and L4 ribosomal proteins. The 25 SE-LMR strains belonged to sequence type ST2, presented SCCmec type III, and two different PFGE patterns. The two SH-LMR strains showed non-typeable SCCmec. SE-LMR strains harboured the resistance genes aac(6’)-aph(2”), and dfrS1. SH-LMR strains contained these genes and the gene erm(C). No lincomycin resistance mechanism was identified in SE-LMR strains regardless of showing lincomycin resistance and diminished susceptibility to clindamycin. Conclusions Linezolid resistance is of concern in hospitals, and requires continued vigilance. Several linezolid resistance mechanisms (mutation in 23S RNAr and amino acid changes in L3 and L4) were identified in this study (AU)

[Characterization of methicillin- and linezolid-resistant Staphylococcus epidermidis and S. haemolyticus strains in a Spanish hospital]. / Caracterización de cepas de Staphylococcus epidermidis y S. haemolyticus resistentes a meticilina y linezolid en un hospital español.

INTRODUCTION: Linezolid resistance is mainly due to mutations in the 23S rRNA target. The aim of this study was to characterize linezolid and methicillin resistant Staphylococcus epidermidis (SE-LM(R)) and S. haemolyticus (SH-LM(R)) strains detected in a Spanish hospital. METHODS: SE-LM(R) and SH-LM(R) strains obtained in the period June 2009-August 2011 in a second level hospital were recorded along with the epidemiological characteristics of the patients. These strains were typed, and their resistance, phenotype, genotype and the factors determining their virulence were analysed. RESULTS: Linezolid resistance was explained by the presence of G2603T mutation (23S rRNA) and aminoacid changes in L3 and L4 ribosomal proteins. The 25 SE-LM(R) strains belonged to sequence type ST2, presented SCCmec typeIII, and two different PFGE patterns. The two SH-LM(R) strains showed non-typeable SCCmec. SE-LM(R) strains harboured the resistance genes aac(6')-aph(2"), and dfrS1. SH-LM(R) strains contained these genes and the gene erm(C). No lincomycin resistance mechanism was identified in SE-LM(R) strains regardless of showing lincomycin resistance and diminished susceptibility to clindamycin. CONCLUSIONS: Linezolid resistance is of concern in hospitals, and requires continued vigilance. Several linezolid resistance mechanisms (mutation in 23S RNAr and amino acid changes in L3 and L4) were identified in this study.

Utilización de las dos arterias torácicas internas en un niño de 9 años con enfermedad de Kawasaki / Utilization of Two Internal Thoracic Arteries in a 9 Year-old Boy with Kawasaki Disease

La enfermedad de Kawasaki es una enfermedad febril aguda infantil. La morbimortalidad se relaciona con la existencia de aneurismas coronarios. Se presenta el caso de un niño de 9 años con diagnóstico de aneurisma gigante del tronco de la arteria coronaria izquierda y múltiples aneurismas medianos en la arteria coronaria derecha. Se le realizó cirugía de revascularización miocárdica con dos arterias torácicas internas. En el control posoperatorio durante 60 meses no presentó síntomas y el estudio de perfusión miocárdica SPECT actual no detecta presencia de isquemia en reposo ni con el esfuerzo. El crecimiento esternal y torácico ha sido normal.

Kawasaki disease is an acute febrile condition affecting children. Morbidity and mortality are related with the existence of coronary aneurysms. This case report is about a 9 year-old boy presenting with a diagnosis of giant main left coronary artery aneurysm and multiple median aneurysms of the right coronary artery. The boy underwent coronary artery by pass surgery graft with two internal thoracic arteries. After 60 months of follow-up, the patient was free of symptoms and the current myocardial perfusion SPECT was negative for ischemia at rest or during exercise. Sternal and thoracic growth has been normal.