Cassia angustifolia and tacrolimus interaction in a liver transplant patient, a case report.

Cassia angustifolia is a species of plant from the Senna family that has traditionally been used as a laxative in different herbal products and commercial medicines. Even though there are few documented drug-plant interactions, the use of C. angustifolia with different drugs may have additive effects, such as with other laxatives or potassium-depleting diuretics. Its use also increases peristalsis which, may reduce drug absorption. The combination with digoxin has been associated with an increased risk of digoxin toxicity, probably due to an increase in plasma digoxin concentrations and hypokalaemia. We present a case with supratherapeutic trough concentration of tacrolimus, an immunosuppressive agent, and a herbal product in a liver transplant patient after concomitant intake of tacrolimus and a herbal product based on C. angustifolia, suggesting a possible drug-lant interaction through by P-glycoprotein. We observed an increase in the patient's blood concentration 2.8-fold and the area under the curve at steady state 2.1-fold. This interaction could be of clinical relevance, given the dose-dependent side effects of tacrolimus, such as nephrotoxicity, neurotoxicity, hypertension, hyperglycaemia, or electrolyte alterations.

Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol.

INTRODUCTION: Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to-discharge) before starting our liver transplant activity and then applied this protocol prospectively to every patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results. PATIENTS AND METHODS: Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early. RESULTS: A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years. CONCLUSION: Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care.

Situación funcional como factor independiente asociado con el mal pronóstico de pacientes ancianos ingresados en Cuidados Intensivos / Functional status as an independent risk factor in elderly patients admitted to an Intensive Care Unit

Objetivo: Evaluar la asociación de la situación funcional previa, valorada mediante la escala de Barthel y Short Form-Late Life Function and Disability instrument, en los pacientes mayores de 74 años que precisan de ingreso en la UCI con respecto a su pronóstico y capacidad funcional al alta hospitalaria. Material y métodos: Estudio prospectivo de una cohorte de paciente mayores de 74 años ingresados en UCI polivalente con estancia superior a 48 h. Se analizan variables demográficas, sociales, comorbilidad, cuestionario de discapacidad (Barthel, Short Form-Late Life Function and Disability instrument), motivos de ingreso en UCI, gravedad en UCI (SAPS 3). Se realiza un análisis multivariable para establecer los factores asociados a mortalidad o mala situación funcional al alta (índice de Barthel menor de 35). Resultados: Durante el periodo del estudio ingresaron 219 pacientes mayores de 74 años, de los que 129 (15%) tuvieron estancia mayor de 48 h. La mediana de edad fue de 80 años (77-83) siendo el 52% mujeres. El motivo de ingreso fue cardiopatía isquémica (19%), otra patología médica (38%) y patología quirúrgica (43%). Un 3% de los pacientes presentaba un Barthel inferior a 36 a su ingreso, siendo la mediana de 95 (85-100). La mediana de estancia en UCI fue de 5 días (4-8). La mortalidad en UCI fue del 6%, con una mortalidad hospitalaria del 10%. Al alta hospitalaria el 7% presentaban dependencia grave (Barthel inferior a 36). En esta población los factores asociados de forma independiente con la mortalidad o mala situación funcional al alta del hospital fueron la situación funcional previa al ingreso, en base a Short Form-Late Life Function and Disability instrument (OR 0,95 IC95%; 0,91 a 0,98); y a la gravedad al ingreso evaluada por SAPS 3 (OR 1,10 IC95%; 1,02 a 1,18) p=0,0007. Conclusiones: En pacientes ancianos que precisan ingreso en UCI, presentar una mayor puntuación en la escala SAPS 3 y deterioro funcional en base a una escala son factores asociados a mortalidad o dependencia severa al alta

Objective: To assess the association of previous functional status in elderly patients admitted to the ICU, estimated by the Barthel and Short Form-Late Life Function and Disability instrument scales, and the relationship with prognosis and functional capacity at hospital discharge. Material and methods: Observational prospective study of ICU-admitted patients older than 74 years, with a length of stay greater than 48hours. Demographic data, social background, comorbidities, disability questionnaire (Barthel, Short Form-Late Life Function and Disability instrument), main diagnosis and severity (SAPS 3) on ICU admission were recorded. Factors associated with mortality or poor functional status at hospital discharge (Barthel Index less than 35) were established by multivariate analysis. Results: During the study period, 219 elderly patients were admitted in ICU, of whom 129 (15%) had an ICU length of stay greater than 48hours. The median age was 80 years (77-83), with 52% women. Main diagnoses on admission included ischaemic heart disease (19%), another medical diagnosis (38%), and surgical procedure (43%). A Barthel score <36 (median 95, 85-100) was observed in 3% of the patients on admission. The median ICU length of stay was 5 days (4-8). ICU mortality was 6% (hospital mortality: 10%). On hospital discharge, 7% had severe dependence (Barthel <36). In this population, factors independently associated with mortality or poor functional status at hospital discharge were the pre-admission functional status, based on Short Form-Late Life Function and Disability instrument (OR 0.95, 95% CI, 0.91 to 0.98), and the severity on admission assessed by SAPS 3 (OR 1.10, 95% CI, 1.02 to 1.18), p=.0007. Conclusions: In elderly patients requiring ICU admission, a higher SAPS 3 score and functional impairment on admission were associated with mortality or severe dependence upon discharge

[Functional status as an independent risk factor in elderly patients admitted to an Intensive Care Unit]. / Situación funcional como factor independiente asociado con el mal pronóstico de pacientes ancianos ingresados en Cuidados Intensivos.

OBJECTIVE: To assess the association of previous functional status in elderly patients admitted to the ICU, estimated by the Barthel and Short Form-Late Life Function and Disability instrument scales, and the relationship with prognosis and functional capacity at hospital discharge. MATERIAL AND METHODS: Observational prospective study of ICU-admitted patients older than 74 years, with a length of stay greater than 48hours. Demographic data, social background, comorbidities, disability questionnaire (Barthel, Short Form-Late Life Function and Disability instrument), main diagnosis and severity (SAPS 3) on ICU admission were recorded. Factors associated with mortality or poor functional status at hospital discharge (Barthel Index less than 35) were established by multivariate analysis. RESULTS: During the study period, 219 elderly patients were admitted in ICU, of whom 129 (15%) had an ICU length of stay greater than 48hours. The median age was 80 years (77-83), with 52% women. Main diagnoses on admission included ischaemic heart disease (19%), another medical diagnosis (38%), and surgical procedure (43%). A Barthel score <36 (median 95, 85-100) was observed in 3% of the patients on admission. The median ICU length of stay was 5 days (4-8). ICU mortality was 6% (hospital mortality: 10%). On hospital discharge, 7% had severe dependence (Barthel <36). In this population, factors independently associated with mortality or poor functional status at hospital discharge were the pre-admission functional status, based on Short Form-Late Life Function and Disability instrument (OR 0.95, 95% CI, 0.91 to 0.98), and the severity on admission assessed by SAPS 3 (OR 1.10, 95% CI, 1.02 to 1.18), p=.0007. CONCLUSIONS: In elderly patients requiring ICU admission, a higher SAPS 3 score and functional impairment on admission were associated with mortality or severe dependence upon discharge.

Myocardial Cleft in a Patient with Acute Coronary Syndrome Assessed by Multimodal Imaging.

Myocardial clefts are rare incidental findings without clinical relevance up to now. The recognition of this imaging entity is of crucial importance to avoid misdiagnosis and even more in the context of coronary artery disease.

Insuficiencia cardiaca, obesidad y apnea del sueño / Heart failure, obesity and sleep apnea

No disponible

No disponible