Reasons for hospitalization and in-hospital mortality for anti-neutrophil cytoplasmic antibody vasculitides: analysis of the National Inpatient Sample.

OBJECTIVE: Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a heterogeneous group of conditions resulting in frequent hospitalizations and high in-hospital mortality (IHM). Our study aimed to use the National Inpatient Sample (NIS) to determine and categorize the main reasons for hospital admission and IHM in patients with AAV. METHODS: We performed a retrospective study of adult AAV hospitalizations in 2016, 2017, and 2018 in acute care hospitals across the USA conducted using the NIS database. We classified the main reasons for hospital admission and IHM into 19 different categories using the principal International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) diagnosis. RESULTS: A total of 41,155 hospitalizations had either a principal or secondary ICD-10 code for AAV (GPA or MPA). Rheumatologic and respiratory diagnoses were the most common reasons for hospitalization, while infectious and respiratory diagnoses were the most common reasons for IHM. Sepsis, unspecified organism A41.9, was the most common specific principal diagnosis for hospitalized and deceased AAV patients. CONCLUSIONS: Our results show that the leading reasons for hospitalization and mortality for AAV patients were rheumatologic, respiratory, and infectious diagnoses. This data suggests that careful monitoring and management of infectious and pulmonary complications in AAV may improve hospital outcomes. Key points • AAV is a heterogeneous group of conditions resulting in frequent hospitalizations and high IHM. In our study, AAV hospitalizations ended in IHM 4.5% of the time, substantially greater than non-ANCA patients. • The leading reasons for hospital admission for AAV patients were rheumatologic and respiratory diagnoses, but the main reason for IHM were infectious and respiratory diagnoses. • Sepsis was the most common principal diagnosis for hospitalized and deceased AAV patients. • Our results highlight the importance of close monitoring and timely management of infectious and respiratory complications to improve hospitalization outcomes.

Unintentional weight loss as presenting form of Whipple's disease. Role of PET-CT scanning and review of the literature

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Association between intraoperative electroencephalographic suppression and postoperative mortality.

BACKGROUND: Low bispectral index values frequently reflect EEG suppression and have been associated with postoperative mortality. This study investigated whether intraoperative EEG suppression was an independent predictor of 90 day postoperative mortality and explored risk factors for EEG suppression. METHODS: This observational study included 2662 adults enrolled in the B-Unaware or BAG-RECALL trials. A cohort was defined with >5 cumulative minutes of EEG suppression, and 1:2 propensity-matched to a non-suppressed cohort (≤5 min suppression). We evaluated the association between EEG suppression and mortality using multivariable logistic regression, and examined risk factors for EEG suppression using zero-inflated mixed effects analysis. RESULTS: Ninety day postoperative mortality was 3.9% overall, 6.3% in the suppressed cohort, and 3.0% in the non-suppressed cohort {odds ratio (OR) [95% confidence interval (CI)]=2.19 (1.48-3.26)}. After matching and multivariable adjustment, EEG suppression was not associated with mortality [OR (95% CI)=0.83 (0.55-1.25)]; however, the interaction between EEG suppression and mean arterial pressure (MAP) <55 mm Hg was [OR (95% CI)=2.96 (1.34-6.52)]. Risk factors for EEG suppression were older age, number of comorbidities, chronic obstructive pulmonary disease, and higher intraoperative doses of benzodiazepines, opioids, or volatile anaesthetics. EEG suppression was less likely in patients with cancer, preoperative alcohol, opioid or benzodiazepine consumption, and intraoperative nitrous oxide exposure. CONCLUSIONS: Although EEG suppression was associated with increasing anaesthetic administration and comorbidities, the hypothesis that intraoperative EEG suppression is a predictor of postoperative mortality was only supported if it was coincident with low MAP. CLINICAL TRIAL REGISTRATION: NCT00281489 and NCT00682825.

Impact of right-handedness on anaesthetic sensitivity, intra-operative awareness and postoperative mortality.

Anatomical, neurological and behavioural research has suggested differences between the brains of right- and non-right-handed individuals, including differences in brain structure, electroencephalogram patterns, explicit memory and sleep architecture. Some studies have also found decreased longevity in left-handed individuals. We therefore aimed to determine whether handedness independently affects the relationship between volatile anaesthetic concentration and the bispectral index, the incidence of definite or possible intra-operative awareness with explicit recall, or postoperative mortality. We studied 5585 patients in this secondary analysis of data collected in a multicentre clinical trial. There were 4992 (89.4%) right-handed and 593 (10.6%) non-right-handed patients. Handedness was not associated with (a) an alteration in anaesthetic sensitivity in terms of the relationship between the bispectral index and volatile anaesthetic concentration (estimated effect on the regression relationship -0.52 parallel shift; 95% CI -1.27 to 0.23, p = 0.17); (b) the incidence of intra-operative awareness with 26/4992 (0.52%) right-handed vs 1/593 (0.17%) non-right-handed (difference = 0.35%; 95% CI -0.45 to 0.63%; p = 0.35); or (c) postoperative mortality rates (90-day relative risk for non-right-handedness 1.19, 95% CI 0.76-1.86; p = 0.45). Thus, no change in anaesthetic management is indicated for non-right-handed patients.

[Parturient at full term with inferior vena cava thrombosis: anesthesia during surgical delivery]. / Gestante a término con trombosis de la vena cava inferior: tratamiento anestésico en el parto.

Emergency cesarean section is a high-risk situation because of potential maternal-fetal complications. We report a case in which risk increased due to a massive thrombus in the mother's left common femoral vein extending to the vena cava. A 31-year-old woman with no relevant medical history in the 41st week of pregnancy was scheduled for induction. Two days before the planned induction she was admitted to the emergency department, where she was diagnosed with deep vein thrombosis in the left lower limb. She was transferred to the postanesthetic recovery unit, where a multidisciplinary team (from gynecology, hematology, interventional radiology, and anesthesiology) discussed various therapeutic options (thrombectomy, vena cava filter, or anticoagulation by intravenous infusion of unfractionated heparin). Given that deep vein thrombosis coincided with obstetric delivery, it was crucial to decide on anesthetic and therapeutic approaches that would assure maternal and fetal safety and prevent such complications as massive pulmonary thromboembolism.

Gestante a término con trombosis de la vena cava inferior: tratamiento anestésico en el parto / Parturient at full term with inferior vena cava thrombosis: anesthesia during surgical delivery

Una cesárea de emergencia es una situación de riesgodebido a las complicaciones potenciales que puede sufrirel binomio materno-fetal. En el caso que presentamos,este riesgo se incrementó por la presencia de un trombomasivo en la vena femoral común izquierda de la madreque se extendía hacia la vena cava. Se trataba de unamujer de 31 años, sin antecedentes de interés y en la 41ªsemana de gestación, que estaba programada parainducción del parto por gestación prolongada. Ingresóen el servicio de urgencias dos días antes de la fecha previstapara la inducción, donde fue diagnosticada detrombosis venosa profunda en el miembro inferiorizquierdo. Fue trasladada a la unidad de recuperaciónpost-anestésica, donde los diferentes servicios implicados(Ginecología, Hematología, Radiología Intervencionistay Anestesiología) debatieron las varias opciones terapéuticas,trombectomía, filtro de vena cava, o el tratamientoanticoagulante con heparina no fraccionada intravenosa.Dado que la trombosis venosa profunda coincidíacon el parto, el tratamiento anestésico y la elección deltratamiento eran trascendentes, para garantizar lamáxima seguridad a la madre y al feto y y prevenir laaparición de complicaciones como un tromboembolismopulmonar masivo(AU)

Emergency cesarean section is a high-risk situationbecause of potential maternal-fetal complications. Wereport a case in which risk increased due to a massivethrombus in the mother’s left common femoral veinextending to the vena cava. A 31-year-old woman withno relevant medical history in the 41st week ofpregnancy was scheduled for induction. Two days beforethe planned induction she was admitted to theemergency department, where she was diagnosed withdeep vein thrombosis in the left lower limb. She wastransferred to the postanesthetic recovery unit, where amultidisciplinary team (from gynecology, hematology,interventional radiology, and anesthesiology) discussedvarious therapeutic options (thrombectomy, vena cavafilter, or anticoagulation by intravenous infusion ofunfractionated heparin). Given that deep veinthrombosis coincided with obstetric delivery, it wascrucial to decide on anesthetic and therapeuticapproaches that would assure maternal and fetal safetyand prevent such complications as massive pulmonarythromboembolism(AU)

Reconstrucción mamaria bilateral: experiencia de los últimos 7 años / Bilateral breast reconstruction: experience of the last 7 years

Se muestra la experiencia clínica en 11 pacientes mujeres portadoras de cáncer mamario bilateral, sometidas a reconstrucción mamaria bilateral con colgajo miocutáneo de recto abdominal bilateral (TRAM), entre abril de 1995 y diciembre de 2001. Se revisaron las fichas clínicas de las pacientes y se tabularon edad, tipo histológico del cáncer, factores de riesgo y complicaciones a corto y largo plazo. Finalmente, se realizó una evaluación subjetiva por las pacientes acerca de los resultados quirúrgicos.

Adaptación a un esquema de entrenamiento físico en pacientes con enfermedad pulmonar obstructiva crónica avanzada / Adaptation to a physical training protocol of severe chronic obstructive pulmonary disease patients

El ejercicio físico es un elemento básico en la rehabilitación en pacientes con EPOC. Sin embargo, los resultados son variables, lo que puede deberse a las diferentes estrategias de entrenamiento utilizadas. En 22 pacientes con EPOC avanzada (VEF, 35,6 ñ 15,7 por ciento: edad 63 ñ 15 años; x ñ DS) Evaluamos su adaptación a un esquema de entrenamiento (E) en bicicleta ergométrica que consistió en aplicar inicialmente una carga inicial de 30 por ciento de la máxima previamente determinada (CM) y aumentarla en 15 a 20 por ciento en las sesiones siguientes cuando el paciente era capaz de mantenerla por 45 minutos, hasta alcanzar la meta de 75 por ciento de la CM. La intensidad del E se midió en watts calculando el área bajo la curva de la relación entre las cargas aplicadas y el número de sesiones de entrenamiento. El efecto del E se evaluó a través de los cambios en la carga y el VO2 máximos, la duración de un ejercicio submáximo, la frecuencia cardíaca, (FC), disnea, fatiga de las extremidades inferiores y lactato sanguíneo para una misma carga y tiempo de ejercicio. La CM de E fue 61 ñ 23 por ciento (x ñ DS) del máximo. Seis pacientes no fueron capaces de alcanzar la carga establecida como meta. En los restantes ésta se alcanzó en un número variable de sesiones (12 ñ 7). La intensidad del entrenamiento fue de 952 ñ 325 watt. El E produjo un aumento de la CM (p<0,02) y del tiempo de ejercicio (p<0,0001) y una disminución significativa de la FC, disnea, fatigabilidad y lactato sanguíneo. La duración del ejercicio se correlacionó con la reducción de la disnea (r= -0,448; p<0,05) y la intensidad del entrenamiento con la disminución de la fatiga (r= -0,5176; p = 0,014) y también del lactato sanguíneo (r= -0,488; p = 0,021). Los resultados demuestran que aún cuando la adaptación al esquema de entrenamiento fue variable de acuerdo a la capacidad individual y no pudo ser aplicada a todos los pacientes, la mayoría de ellos obtuvo efectos beneficiosos

Calidad de vida en pacientes con enfermedad pulmonar obstructiva crónica e impacto del entrenamiento físico / Quality of life in patients with chronic pulmonary obstructive disease and the impact of physical training

Background: Health related quality of life (QoL) is severely impaired in COPD patients as a consequence of dyspnea and limited exercise tolerance, which lead to physical deconditioning and muscle atrophy resulting in weakness and fatigue. Psychosocial factors such as depression and anxiety also contribute to this impairment. Aim: To evaluate: a) the impact of COPD on quality of life, and b) the effect of 10 weeks of exercise training on exercise performance and on QoL. Patients and methods: The Spanish version of the Chronic Respiratory Questionnaire (CRQ) was applied to 55 COPD patients (FEV1 37 ñ 13 percent pred) for the assessment of QoL and in 30 of them submitted to exercise training for 10 weeks. Exercise performance was evaluated by measuring: six-minute walking distance, maximal workload (Wmax), maximal O2 consumption (VO2max) as well as endurance time, blood lactic acid, dyspnea and leg fatigue during a submaximal exercise. Trained patients were evaluated before and after training. Results : COPD patients showed a reduction (mean ñ SD) in the four domains of the CRQ: dyspnea (3.1 ñ 0.9); fatigue (4.3 ñ 1.3); mastery (4.65 ñ 1.3), emotional function (4.1 ñ 0.97), and in Wmax and VO2max (52 ñ 16 Watt and 970 ñ 301 ml/min). No significant relationship between the impairment in exercise tolerance and in QoL was observed. Exercise training significantly improved the four domains of QoL (p < 0.0001), Wmax (p < 0.05), VO2max (p < 0.02) and endurance time (p < 0.001). Isotime exercise measurements of dyspnea, leg fatigue and lactic acid decreased after training (p < 0.001, each). No significant relation between changes in QoL and changes in exercise performance were observed. Conclusions: Our results demonstrate that QoL is seriously impaired in patients with COPD and confirm: (a) the lack of relationship of QoL to the usually measured physiological parameters, and (b) the beneficial effect of exercise training on QoL through the reduction of symptoms. These findings stresses the need of measuring quality of life in our patients if we want to evaluate the impact of therapeutic procedures on well-being from the patients' perspective

Efecto del entrenamiento muscular inspiratorio en el costo de oxígeno de la ventilación en pacientes con enfermedad pulmonar obstructiva crónica / Effects of inspiratory muscle training on the oxygen cost of breathing in patients with chronic obstructive pulmonary disease

Background: Patients with chronic obstructive pulmonary disease have an increased inspiratory work, since they must overcome high loads due to increased airway resistance. Aim: To determine if the reduction in the metabolic cost of exercise observed in patients with chronic obstructive pulmonary disease (COPD) after inspiratory muscle training, was due to a reduction in the oxygen cost of breathing. Patients and methods: Nine patients with COPD (FEV1 39 ñ 13 percent) subjected to inspiratory muscle training, using a training load of 30 percent of maximal inspiratory pressure, during 10 weeks; 5 patients with COPD (FEV1 44 ñ 18 percent) not subjected to training, and 7 healthy controls (FEV1 110 ñ 10 percent) were studied. The cost of breathing was calculated as the difference in VO2 measured at rest and after breathing a gas mixture containing air and 5 percent CO2. Exercise VO2 was measured at submaximal exercise. Results: Oxygen cost of breathing was increased in patients with COPD and it was inversely correlated with FEV1 (r= -0.86 p<0.001). Inspiratory muscle training increased maximal inspiratory pressure and decreased exercise VO2. Oxygen cost of breathing increased in six and decreased in three trained patients. Changes in this parameter after training did not correlate with the reduction in exercise VO2 or the increment in maximal inspiratory pressure. Conclusions: The reduction in exercise VO2 after inspiratory muscle training is not due to a reduction in the oxygen cost of breathing

Efectos clínicos del entrenamiento muscular inspiratorio en pacientes con limitación crónica del flujo aéreo / Clinical effects of inspiratory muscular training in patients with chronic airway flow limitation

The clinical role of inspiratory muscular training (IMT) in chronic obstructive pulmonary disease (COPD) has not been established, because data on its clinical effect is scarce and controversial. To further investigate these aspects we studied 20 COPD patients (FEV1 37ñ3 percent P) who were randomly and double blindy trained for 30 minutes a day during 10 weeks using a threshold inspiratory trainer with either 30 percent (group 1) or 10 percent (group 2) of PIMax as a training load. The training load was cossed after each patient completed 10 weeks of training. Effects were assessed through changes in PIMax, dyspnea through the transition dyspnea index (ITD) and the respiratory effort with Borg's score. Walking capacity was measured with the six minutes walking distance test (6WD) and depression symptoms with Beck's score. Daily life activities were also assessed. Results showed that after 10 weeks of IMT, PIMax increased in both groups (p<0.05), dyspnea improved in group 1 as compared to group 2 (p<0.04), 6WD increased significantly in group 1 disclosed a significant deterioration in PIMax whereas group 2 disclosed significant improvements in PIMax, dyspnea and 6WD. We conclude that IMT using a threshold device with 30 percent PIMax is a useful procedure for the treatment of severe COPD patients

Entrenamiento muscular inspiratorio en pacientes con obstrucción bronquial crónica: factores relacionados con la mejoría de la disnea / Inspiratory muscular training in patients with chronic bronchial obstruction: factors related to improvement in dyspnea

Estudiamos 20 pacientes con OBC (VEF1/CVF 37 . 3 porciento) que fueron asignados en forma aleatoria y doble ciego a EMI por 10 semanas con una válvula umbral, empleando un 30 porciento (grupo 1) o un 10 porciento (grupo 2) de la PIMax como carga de entrenamiento. Los cambios en la disnea se evaluaron con el índice de transición de la disnea (ITD) que fue correlacionado con cambios en la máxima carga de ejercicio, VE y VO2 de un ejercicio submáximo, VEF1, PIMax, carga máxima inspiratoria sostenible, potencia máxima de los músculos inspiratorios y síntomas depresivos. Los resultados demostraron una mejoría significativa de la función muscular inspiratoria en los dos grupos. Los pacientes del grupo 1 presentaron además un mayor alivio de la disnea (p<0,05) y de la potencia de los MI (p<0,05) y disminuyeron la VE y el VO2 del ejercicio (p<0,001). Se observó una correlación significativa entre los cambios de la VE y VO2 de un determinado ejercicio en el grupo 1 (r=0,92; p<0,001). El análisis de correlación múltiple demostró como único factor relacionado con el ITD el cambio del VO2 del ejercicio (r=-0,52; p<0,02). La relación con los cambios en la VE no alcanzó significación estadística (p=0,07). Se concluye que el alivio de la disnea producida por el EMI está relacionado con el menor costo metabólico del ejecicio, probablemente derivado de la menor VE del ejercicio o de un aumento de la eficiencia de los músculos inspiratorios

Efecto del entrenamiento muscular inspiratorio por tiempo prolongado en pacientes con limitación crónica del flujo aéreo / Prolongued inspiratory muscle training in chronic airflow limitations

El efecto del entrenamiento musclar inspiratorio (EMI) en pacientes con limitación crónica del flujo aéreo (LCFA) ha sido evaluado sólo por períodos cortos (2-6 meses). Se ha demostrado que si se utiliza una carga de EMI suficiente, aumenta la fuerza y la resistencia a la fatiga de estos músculos. Algunos autores han observado además, alivio de la disnea y de la capacidad para realizar ejercicios físicos. Con el propósito de evaluar si el EMI por un tiempo más prolongado es capaz de aumentar estos efectos beneficiosos, entrenamos 8 pacientes con LCFA de 70.4ñ6.3 años de edad y VEF1 37.7ñ7.8 porciento del teórico. El EMI se realizó en el domicilio con una válvula umbral durante 30 minutos por 5 días a la semana. La evaluaciones demuestran que el EMI prolongado mantiene el aumento logrado a los 4 meses de la fuerza y resistencia a la fatiga, de la mejoría de la disnea y de la calidad de vida (p<0.001) junto a la optimización de la estrategia respiratoria para inspirar contra cargas externas. En cambio, a 18 meses de EMI no se mantuvo aumento observado a los 4 meses de la potencia y del flujo inspiratorio máximo. Se concluye que el EMI por tiempo prolongado en pacientes con LCFA logra mantener la mayoría de los cambios beneficiosos obtenidos en el largo plazo. La disminución de los índices que influyen en el flujo inspiratorio podría deberse a la transformación que experimentan con el EMI crónico las fibras glicolíticas rápidas a fibras oxidativas cuya velocidad de contracción es más lenta

Uso de pentoxifilina en pacientes sometidos a hemodiálisis crónica / Pentoxiphylline use in patients submitted to chronic hemodyalisis

Se ha comunicado que la pentoxifilina mejora el flujo de la microcirculación esplácnica. El presente trabajo estudia el efecto de este fármaco en 7 pacientes sometidos a hemodiálisis crónica. Se observó la respuesta ventilatoria (L/min), evolución de gases arteriales y lactato sérico en hemodiálisis con capilar de cuprofán nuevo y de sexto uso. Se comprueba la hipoxemia aguda que ocurre en los enfermos sometidos a hemodiálisis corroborándose una marcada hipoventilación alveolar que no se modifica con la droga xantínica. Se observa un descenso del lactato sérico con la hemodiálisis (p<0.05) que, con el uso de la pentoxifilina, se hace más significativo estadísticamente (p<0.01) cuando se utilizó filtro de cuprofán nuevo. En cambio, cuando se utilizó filtro de cuprofán de sexto uso, hubo un descenso del ácido láctico, sin alcanzar significación estadística (p>0.05)