Role Of Intravenous Iron Over Nonsurgical Transfusions In Major Burns.

Anemia is a frequent condition in burn patients due to a mixture of blood loss and chronic inflammation. Transfusions increase the probability of serious infections and reduce overall survival, especially when unrelated to perioperative blood loss. Once the surgical phase in burn patients is completed, the role of parenteral iron administration in the reduction of subsequent transfusions is not well established. Burn patients subjected to at least two surgeries and presenting progressive anemia after concluding the surgical phase, without major symptoms, were selected (n=12). Those patients with confirmed iron deficiency were treated with intravenous (i.v.) ferric carboxymaltose (n=8). Subsequently, these patients were compared with a group of 18 control patients selected from our historical database (n=1375), matching controls by age (±5 years), sex, and TBSA burn (±6%). The objective was to verify if i.v. iron administration reduced the need for blood transfusions after the surgical phase. The analysis concluded that none of the cases treated required transfusions compared to 44% of the controls. There were no side effects related to the i.v. iron infusion. This result suggests that i.v. iron supplementation with ferric carboxymaltose could be an alternative in anemic patients without major symptoms once the surgical phase is completed. Iron deficiency should be assessed and i.v. supplementation must be administered if required in burn patients showing progressive anemia.

L'anémie, à la fois par pertes sanguines et inflammation, est fréquente chez les brûlés. Les transfusions, en particulier lorsque l'anémie n'est pas liée à la chirurgie, sont corrélées à la survenue d'infections sévères et à la mortalité. Une fois la phase chirurgicale terminée, le rôle de la thérapie martiale intraveineuse sur l'épargne transfusionnelle est mal connu. Nous avons évalué 12 patients brûlés, ayant été opérés au moins 2 fois et ne devant plus l'être, qui développaient une anémie progressive bien tolérée. Les 8 patients ayant une carence martiale ont reçu du carboxymaltose ferrique intraveineux. Ils ont été comparés avec 18 patients témoins, sélectionnés dans notre base de données de 1 375 dossiers, appariés sur l'âge +/- 5 ans, le sexe et la surface brûlée +/- 6%, l'objectif étant de vérifier si le traitement permettait effectivement de réduire les transfusions. Effectivement, aucun des patients traités n'a été transfusé, contre 44% des témoins. Aucun effet secondaire n'a été observé après administration de fer. Ceci suggère que des patients brûlés, chirurgie terminée, anémiques pauci- symptomatiques par carence martiale devraient recevoir un traitement martial IV.

Evaluación de la respuesta sistémica en el postoperatorio de las cardiopatías congénitas / Evaluation of the postoperative systemic response in congenital heart defects

No disponible

Epidemiología y pronóstico tardío de la sepsis en ancianos / Epidemiology and long-term outcome of sepsis in elderly patients

OBJETIVOS: Examinar los datos epidemiológicos de pacientes sépticos mayores de 65 años con ingreso en UCI e identificar predictores de supervivencia a 2 años. DISEÑO: Estudio de cohortes prospectivo. PACIENTES: Criterios de sepsis al ingreso a UCI. Ámbito: UCI de 40 camas en un hospital terciario. RESULTADOS: El estudio incluyó a 237 pacientes ancianos (≥ 65 años de edad) y 281 controles (< 65 años), n = 518. Al menos una enfermedad subyacente estaba presente en el 70% de los pacientes ancianos en comparación con solo el 56,1% en controles (p < 0,01). Entre los mayores de 65 años se registró mayor prevalencia de enfermedades crónicas (diabetes, enfermedad obstructiva pulmonar crónica e insuficiencia cardíaca crónica), presentación más frecuente como shock séptico (52,3 vs. 42%; p < 0,05) y abdomen como foco (52 vs. 36%; p < 0,01). El 9% de los pacientes dados de alta hospitalaria falleció en el seguimiento posterior de 2 años, aumentando hasta el 20% en los ancianos. Los predictores independientes de mortalidad a 2 años en los pacientes ancianos fueron: insuficiencia cardíaca crónica (hazard ratio ajustada [aHR] 2,24; intervalo de confianza del 95% [IC 95%] 1,28-3,94; p < 0,01), insuficiencia renal aguda (aHR 3,64; IC 95% 2,10-6,23; p < 0,01), insuficiencia respiratoria aguda (aHR 3,67; IC 95%: 2,31-5,86; p < 0,01) y antibioterapia empírica inadecuada (aHR 2,19; IC 95% 1,32-3,62; p < 0,01).Conclusiones La sepsis en mayores de 65 años presenta diferencias relevantes en sus características demográficas y presentación clínica. Tras ajustar por potenciales factores de confusión, la terapia antimicrobiana empírica inadecuada se asoció con una reducción del doble en la supervivencia a los 2 años

OBJECTIVES: A study was made of the epidemiological data of sepsis requiring admission to the ICU in patients over 65 years of age, with an evaluation of independent predictors of survival at 2 years. DESIGN: A prospective cohort study was made. PATIENTS: Patients meeting criteria for sepsis upon admission to the ICU. SETTING: A 40-bed ICU in a tertiary hospital. RESULTS: The study group included 237 elderly patients (≥ 65 years of age) and 281 controls (< 65 years of age) (n = 518). At least one chronic comorbid condition was present in 70% of the elderly patients as compared to only 56.1% of patients under age 65 (P < .01). There were several epidemiological differences between the groups: the prevalence of chronic diseases (diabetes, chronic obstructive pulmonary disease, and chronic heart failure), presentation as septic shock (52.3% vs 42%; P < .05), and the abdomen as the source of sepsis (52% vs 36%; P < .01) were all more frequent in elderly patients. Nine percent of the global patients discharged from hospital died in the 2-year follow-up period, but this rate reached 20% among the elderly. Independent predictors of 2-year mortality in the elderly were: chronic heart failure (adjusted hazard ratio [aHR] 2.24, 95% confidence interval [CI 95%] 1.28-3.94; P < .01), acute renal failure (aHR 3.64, 95%CI 2.10-6.23; P < .01), acute respiratory failure (aHR 3.67, 95%CI 2.31-5.86; P < .01), and inappropriate empirical antimicrobial therapy (aHR 2.19, 95%CI 1.32-3.62; P < .01). CONCLUSIONS: Sepsis showed different demographic characteristics and clinical presentations in the elderly. In the aging cohort, after adjusting for potential confounders, inadequate empirical antimicrobial therapy was associated to a 2-fold decrease in survival at two years

[Epidemiology and long-term outcome of sepsis in elderly patients]. / Epidemiología y pronóstico tardío de la sepsis en ancianos.

OBJECTIVES: A study was made of the epidemiological data of sepsis requiring admission to the ICU in patients over 65 years of age, with an evaluation of independent predictors of survival at 2 years. DESIGN: A prospective cohort study was made. PATIENTS: Patients meeting criteria for sepsis upon admission to the ICU. SETTING: A 40-bed ICU in a tertiary hospital. RESULTS: The study group included 237 elderly patients (≥ 65 years of age) and 281 controls (<65 years of age) (n=518). At least one chronic comorbid condition was present in 70% of the elderly patients as compared to only 56.1% of patients under age 65 (P<.01). There were several epidemiological differences between the groups: the prevalence of chronic diseases (diabetes, chronic obstructive pulmonary disease, and chronic heart failure), presentation as septic shock (52.3% vs 42%; P<.05), and the abdomen as the source of sepsis (52% vs 36%; P<.01) were all more frequent in elderly patients. Nine percent of the global patients discharged from hospital died in the 2-year follow-up period, but this rate reached 20% among the elderly. Independent predictors of 2-year mortality in the elderly were: chronic heart failure (adjusted hazard ratio [aHR] 2.24, 95% confidence interval [CI 95%] 1.28-3.94; P<.01), acute renal failure (aHR 3.64, 95%CI 2.10-6.23; P<.01), acute respiratory failure (aHR 3.67, 95%CI 2.31-5.86; P<.01), and inappropriate empirical antimicrobial therapy (aHR 2.19, 95%CI 1.32-3.62; P<.01). CONCLUSIONS: Sepsis showed different demographic characteristics and clinical presentations in the elderly. In the aging cohort, after adjusting for potential confounders, inadequate empirical antimicrobial therapy was associated to a 2-fold decrease in survival at two years.

Extracción de oxígeno como predictor de mortalidad en pacientes con ventilación con alta frecuencia / Oxygen extraction as a predictor of mortality in patients on high frequency ventilation

Introducción: La ventilación con alta frecuencia (VAFO) puede reducir el gasto cardíaco. Analizamos su repercusión hemodinámica e identificamos factores pronósticos de mortalidad. Pacientes y métodos: Entre enero del 2003 y diciembre del 2010, incluimos a 48 niños con fallo respiratorio sometidos a VAFO. El diseño del estudio fue prospectivo, observacional y descriptivo. Los criterios de inclusión se basaron en la existencia de hipoxemia. Las variables estudiadas fueron: presiones arterial y venosa central, pH arterial, saturación venosa e índice de extracción de oxígeno; haciéndose determinaciones previas a la VAFO, durante y antes de pasar a convencional. Se identificaron factores pronósticos mediante un análisis bivariante y determinamos un modelo predictivo de mortalidad. Resultados: La edad fue de 21 (4-72) meses. Al ingreso, las escalas de PRISM y Murray fueron de 33 y de 2,8, la PaO2/FiO2 de 61 y el índice de oxigenación de 35. Tras la VAFO, se obtuvo un aumento del pH (p>0,001), de la presión arterial media (p<0,001) y de la saturación venosa, y un descenso de la presión venosa y de la extracción de O2 (p < 0,001). Los factores pronósticos de mortalidad a las 24 h de iniciar la VAFO fueron: FiO2, PaO2/FiO2, índice de oxigenación, shunt, pH, presiones venosa central y arterial media, saturación venosa y extracción de O2. El modelo creado a las 12 h, compuesto por la SvcO2 y el ETO2, fue capaz de pronosticar la muerte con una probabilidad del 92,3%. Conclusiones: La VAFO mejora la hemodinámica. El modelo a las 12 h es el que mejor nos predice la muerte(AU)

Introduction: The high frequency oscillatory ventilation (HFOV) may reduce cardiac output. The haemodynamics were analysed and predictors of mortality identified. Patients and methods: A total of 48 children with respiratory failure undergoing HFOV between January 2003 and December 2010 were included. The study design was prospective, observational, and descriptive. Inclusion criteria were based on the existence of hypoxemia. The variables studied were: arterial and central venous pressure, arterial pH, venous saturation and oxygen extraction ratio, with determinations performed prior to HFOV, during, and before turning to conventional ventilation. Prognostic factors were identified by bivariate analysis and a predictive model of mortality was developed. Results: The mean age was 21 [4 to 72] months. On admission, PRISM scales and Murray were 33 and 2.8, PaO2/FiO2 of 61 and oxygenation index of 35. After HFOV an increase in pH (P<0.001), mean arterial pressure (P<0.001) and venous saturation, and decreased venous pressure and O2 extraction (P<0.001), was obtained. The prognostic factors of mortality at 24hours after starting HFOV were: FiO2, PaO2/FiO2, oxygenation index, shunt, pH, central venous pressure and mean arterial pressure, venous saturation, and O2 extraction. The model developed at 12hours, consisting of EtO2 and SvcO2 was able to predict death with a probability of 92.3%. Conclusions: HFOV improves haemodynamics. The model at 12hours is the best predictor of death(AU)

[Oxygen extraction as a predictor of mortality in patients on high frequency ventilation]. / Extracción de oxígeno como predictor de mortalidad en pacientes con ventilación de alta frecuencia.

INTRODUCTION: The high frequency oscillatory ventilation (HFOV) may reduce cardiac output. The haemodynamics were analysed and predictors of mortality identified. PATIENTS AND METHODS: A total of 48 children with respiratory failure undergoing HFOV between January 2003 and December 2010 were included. The study design was prospective, observational, and descriptive. Inclusion criteria were based on the existence of hypoxemia. The variables studied were: arterial and central venous pressure, arterial pH, venous saturation and oxygen extraction ratio, with determinations performed prior to HFOV, during, and before turning to conventional ventilation. Prognostic factors were identified by bivariate analysis and a predictive model of mortality was developed. RESULTS: The mean age was 21 [4 to 72] months. On admission, PRISM scales and Murray were 33 and 2.8, PaO(2)/FiO(2) of 61 and oxygenation index of 35. After HFOV an increase in pH (P<.001), mean arterial pressure (P<.001) and venous saturation, and decreased venous pressure and O(2) extraction (P<.001), was obtained. The prognostic factors of mortality at 24 hours after starting HFOV were: FiO(2), PaO(2)/FiO(2), oxygenation index, shunt, pH, central venous pressure and mean arterial pressure, venous saturation, and O(2) extraction. The model developed at 12 hours, consisting of EtO(2) and SvcO(2) was able to predict death with a probability of 92.3%. CONCLUSIONS: HFOV improves haemodynamics. The model at 12 hours is the best predictor of death.

Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión / Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging

Objetivos. Evaluar la relación entre el material recogido en filtros distales tras angioplastia y colocación de stent carotídeo (ASC) y la aparición de lesiones isquémicas cerebrales en la RM potenciada en difusión (RMD). Determinar la influencia que tienen variables demográficas, clínicas y del procedimiento en el proceso embolígeno y en la isquemia post-ASC. Material y método. Se analizó histológicamente el contenido de los filtros de 76 pacientes sometidos a ASC por estenosis grave de la arteria carótida interna (ACI) (60 hombres; edad media 68,39 años; rango: 46-82), valorándose el volumen (< 1 λ=0,001 ml=1μl; 1-10 λ; y > 10 λ) y la composición de las partículas. Se realizó RMD previa y 24h después del procedimiento, recogiéndose la aparición de lesiones, número, tamaño y distribución. Se correlacionaron estadísticamente los datos anteriores y con variables demográficas, clínicas y del procedimiento. Resultados. Cincuenta y ocho pacientes (76,3%) presentaron sintomatología previa al procedimiento. El 64,5% de los filtros (49) presentó partículas, la mayoría menores de 1 λ (77,5%), predominando los agregados fibrinoplaquetarios, restos celulares y cristales de colesterol. Doce pacientes (15,8%) demostraron lesiones en la RMD post-ASC, sin relación con el contenido en los filtros. No se encontró correlación estadística entre la presencia de material en los filtros y otras variables. Conclusiones. La isquemia post-ASC no depende únicamente de la carga embolígena y su naturaleza. La menor prevalencia de lesiones post-ASC en nuestra serie en comparación con otras indica que la adecuada selección de pacientes y la experiencia minimizan la influencia negativa de algunas variables, como la edad, en su aparición (AU)

Objectives. To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting. Material and methods. We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ=0.001ml = 1μl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. Results. Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. Conclusions. Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development(AU)

Evaluación de la revisión telefónica en la recurrencia de ictus y AIT / Evaluation of telephone assessment in stroke and TIA recurrence

Introducción: La recurrencia de ictus o AIT es un aspecto clave en la mayoría de los registros de ictus, pero la revisión presencial de todos los pacientes no siempre es viable. Con frecuencia, la revisión telefónica es utilizada para evaluar las recurrencias, la situación funcional y los tratamientos a largo plazo. El objetivo es evaluar la revisión telefónica en un registro de ictus. Material y métodos: Se registraron prospectivamente 380 pacientes con ictus o AIT valorando las características basales y tipo de evento. Posteriormente, fueron evaluados a los 6 meses tras el evento inicial. Doscientos cuarenta y ocho pacientes fueron revisados telefónicamente mediante una entrevista estructurada y 132 fueron revisados físicamente en consulta. Se compararon ambos grupos analizando las diferencias detectadas en las escalas funcionales, tratamientos y recurrencias (AIT o ictus). Resultados: No hubo diferencias en las características basales de ambos grupos, ni en el tipo de evento o gravedad al inicio. A los 6 meses, los tratamientos realizados fueron similares en ambos grupos, presentando un 10,5% (40 pacientes) recurrencia de ictus o AIT. No hubo diferencias significativas en la tasa de nuevos ictus isquémicos (6,1% revisión física vs 4,4% telefónica, p=0,49), pero se detectó un mayor número de AIT en la revisión física frente a la telefónica (9,1% vs 4,0%, p=0,04). Conclusiones: La revisión telefónica de los pacientes con ictus es viable y facilita la realización de registros de ictus, permitiendo una adecuada identificación de los tratamientos y recurrencias de ictus. Sin embargo, es probable que los nuevos eventos transitorios o AIT estén infraestimados (AU)

Introduction: Stroke recurrence is an important issue in stroke registries, but direct patient contact months after stroke is not always feasible. Telephone assessment is often used to evaluate long term stroke outcome, treatments and recurrences. Our aim is to evaluate telephone interview in a stroke registry. Material and methods: Three hundred and eighty patients with a stroke or TIA were prospectively registered, evaluating baseline characteristics and type of event. At 6 months, 248 patients were reviewed by structured telephone interview and 132 were reviewed by direct contact. We analysed stroke outcome and disability, treatments and stroke or TIA recurrences. Results: There were no differences in baseline characteristics and type or severity of the index event. At 6 months, treatments were similar between both groups and 10.5% (40 patients) had a recurrent event. There were no differences in recurrent ischaemic strokes (6.1% in direct contact vs 4.4% telephone, P=.49), but we detected a higher number of TIA in direct examination compared to phone interview (9.1% vs 4.0%, P=.04). Conclusions: Telephone assessment of stroke patients is reliable and facilitates stroke registries in detecting long-term treatments and stroke recurrences. However, it is probable that new transient events or TIA are under-estimated (AU)

[Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging]. / Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión.

OBJECTIVES: To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting. MATERIAL AND METHODS: We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39 years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ = 0.001 ml = 1 µl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24 hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. RESULTS: Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. CONCLUSIONS: Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development.

[Evaluation of telephone assessment in stroke and TIA recurrence]. / Evaluación de la revisión telefónica en la recurrencia de ictus y AIT.

INTRODUCTION: Stroke recurrence is an important issue in stroke registries, but direct patient contact months after stroke is not always feasible. Telephone assessment is often used to evaluate long term stroke outcome, treatments and recurrences. Our aim is to evaluate telephone interview in a stroke registry. MATERIAL AND METHODS: Three hundred and eighty patients with a stroke or TIA were prospectively registered, evaluating baseline characteristics and type of event. At 6 months, 248 patients were reviewed by structured telephone interview and 132 were reviewed by direct contact. We analysed stroke outcome and disability, treatments and stroke or TIA recurrences. RESULTS: There were no differences in baseline characteristics and type or severity of the index event. At 6 months, treatments were similar between both groups and 10.5% (40 patients) had a recurrent event. There were no differences in recurrent ischaemic strokes (6.1% in direct contact vs 4.4% telephone, P=.49), but we detected a higher number of TIA in direct examination compared to phone interview (9.1% vs 4.0%, P=.04). CONCLUSIONS: Telephone assessment of stroke patients is reliable and facilitates stroke registries in detecting long-term treatments and stroke recurrences. However, it is probable that new transient events or TIA are under-estimated.

Dyslipidemia as a long-term marker for survival in pulmonary embolism.

OBJECTIVES: To analyse survival rate after 24 months in consecutive patients with a diagnosis of PE as well as associated factors. METHODS: Prospective cohort study during a follow-up period of two years in a series of consecutive patients with PE. RESULTS: During the follow-up period, 34 out of 148 patients died (23%). Factors independently associated with reduced survival rate were: creatinine levels > 2 (OR, 8.8; 95% CI, 1.1 - 70.87), previous neoplasm (OR, 8.8; 95% CI, 3.69 - 20.98), dementia (OR, 6.85; 95% CI, 2.1 - 22.33) and dyslipidemia (OR, 5.07; 95% CI, 1.92 - 13.44). Forty four percent of the patients with dyslipidemia died vs. 20.8% of patients without this condition. CONCLUSIONS: In our study dyslipidemia shows as a long-term negative prognostic marker for survival in patients with EP.

[Improving the outcomes in spontaneous subarachnoid haemorrhage: the EHSA project]. / Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA.

AIM: To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgical management of spontaneous subarachnoid haemorrhages (SAH). PATIENTS AND METHODS A prospective, longitudinal cohort study was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 public hospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acute haemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medical and surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latter was then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due to rebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentially avoidable deaths. RESULTS: A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155 patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension, coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. CONCLUSIONS: Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors.

Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA / Improving the outcomes in spontaneous subarachnoid haemorrhage: The Ehsa project

Objetivo. Investigar nuestras prácticas clínicas, a fin de identificar oportunidades de mejora en el manejo medicoquirúrgicode las hemorragias subaracnoideas (HSA) espontáneas. Pacientes y métodos. Estudio de cohortes, longitudinal,prospectivo, de las HSA atendidas consecutivamente en los servicios de cuidados críticos y urgencias de 29 hospitales públicosde Andalucía durante 20 meses, de 2000 a 2002. Se consideraron HSA los accidentes cerebrovasculares hemorrágicosagudos con este diagnóstico tomográfico. Se analizaron los resultados a 12 meses y el manejo asistencial (terapéutica médicay quirúrgica, técnicas diagnósticas, tiempos asistenciales y complicaciones neurológicas específicas), comparándolo conlas prácticas clínicas que la evidencia científica ha demostrado de mayor utilidad. Se catalogaron como muertes potencialmenteevitables los óbitos por resangrado en pacientes sin estudio arteriográfico o sin exclusión del aneurisma. Resultados.Se incluyeron 506 HSA. Se perdió durante el seguimiento el 5% de la muestra. Fallecieron 155 enfermos. Las variables no modificablesde riesgo independiente para la mortalidad fueron: edad, género masculino, antecedente de hipertensión arterial,coma a la recepción hospitalaria e hidrocefalia. Las variables influenciables de riesgo independiente para fallecer resultaronser: ausencia de analgesia urgente, carencia de diagnóstico arteriográfico, aparición de deterioro neurológico isquémico yresangrado. El 20% de la mortalidad global podría considerarse potencialmente evitable. Conclusiones. Aunque la letalidades mayoritariamente dependiente de variables médicamente no influenciables (sexo, edad, antecedentes, gravedad clínica ehidrocefalia), los decesos, en un 20%, están asociados a factores modificables (AU)

Aim. To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgicalmanagement of spontaneous subarachnoid haemorrhages (SAH). Patients and methods. A prospective, longitudinal cohortstudy was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 publichospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acutehaemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medicaland surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latterwas then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due torebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentiallyavoidable deaths. Results. A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension,coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. Conclusions. Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors (AU)

Skull fracture, with or without clinical signs, in mTBI is an independent risk marker for neurosurgically relevant intracranial lesion: a cohort study.

PRIMARY OBJECTIVE: To explore the possibility of identifying skull fracture, with or without clinical signs, as a predictor of positive CT scans in mild traumatic brain injury (mTBI). RESEARCH DESIGN: Prospective cohort study, matched 1:1 for five potential confounding variables (age, sex, symptoms, mechanism of injury and extracranial trauma severity). METHODS AND PROCEDURES: The study was performed on patients with mTBI (Glasgow Coma Scale 15-14), with or without radiologically demonstrated skull fracture. The cohort with skull fracture included 155 patients selected from a sample of 5097 mTBI patients treated during 1998 at the Critical Care and Emergency Department of the Trauma Centre. The cohort without skull fracture was prospectively recruited from patients with mTBI treated in the same department from 2002-2005. MAIN OUTCOMES AND RESULTS: The percentage of patients with intracranial lesion (IL) was significantly higher in mTBI patients with skull fracture than in those without. The risk of requiring neurosurgery was 5-fold higher when skull fracture was present. Of mTBI patients with skull fracture and IL, 63.2% showed no clinical signs of bone injury. CONCLUSIONS: Skull fracture, with or without clinical signs, in mTBI patients is associated with an increased risk of neurosurgically-relevant intracranial lesion.

[Diverging trends in prostate cancer mortality in the autonomous community of Andalucia (1975-2004)]. / Tendencias divergentes en la mortalidad por cáncer de próstata en la comunidad autónoma de Andalucía (1975-2004).

OBJECTIVE: To describe the evolution of prostate cancer mortality in Andalucia during the period 1975-2004 at the provincial level. SUBJECTS AND METHOD: Mortality data for prostate cancer and population denominator data was supplied by the Statistical Institute of Andalucia. Age group-specific and standardised overall and truncated (50-79 years old) rates were calculated by the direct method (European standard population). RESULTS: In 2004 there were 813 deaths in Andalucia from prostate cancer. Prostate cancer accounts for around 8% of male deaths from cancer. Joinpoint analysis shows three diverging trends (fall in Cadiz, Huelva and Malaga, rise in Granada and stabilization in the other provinces) in age-standardized mortality rates. CONCLUSION: In Granada, an increment in mortality from prostate cancer is observed in opposition to the trend in the other provinces.

Análisis clínico-epidemiológico de pacientes consecutivos con tromboembolismo pulmonar / Clinical-epidemiological analysis of consecutive patients with pulmonary thromboembolism

INTRODUCCIÓN: El tromboembolismo pulmonar (TEP) constituye un problema sanitario de gran trascendencia debido a su elevada morbimortalidad. La enfermedad tromboembólica venosa (ETV) ocasiona unas 300.000 hospitalizaciones al año, con una incidencia del 0,5 al 2,5% entre los pacientes ingresados por patología médica y del 0,1 al 0,6% de los ingresados por causa quirúrgica. La prevalencia entre los ingresados es aproximadamente del 1%.OBJETIVO: Estudiar las características de los pacientes ingresados por TEP en nuestro medio hospitalario a fin de poder valorar la epidemiología, los factores de riesgo y la evolución durante el periodo agudo. PACIENTES Y MÉTODO: Se estudiaron a todos los pacientes ingresados y diagnosticados de TEP en los Hospitales Universitarios Virgen del Rocío de Sevilla en el periodo comprendido desde febrero de 2003 hasta septiembre del 2004. Se realizó una sistemática recogida de datos clínicos, diagnósticos, y evolutivos hasta el alta hospitalaria. RESULTADOS: Durante 19 meses consecutivos un total de456 pacientes ingresaron en nuestra área hospitalaria por sospecha de TEP. De estos sólo en 165 casos (36%) se confirmó dicho diagnóstico. Ochenta y dos (49.7%) eran mujeres y ochenta y tres hombres (50.3%). La edad media de fue de 64.47±16.77. El factor de riesgo para la ETV presente con más frecuencia fue la inmovilización secundaria. Los síntomas de presentación más frecuente fueron la disnea y el dolor torácico. El electrocardiograma fue normal en la mayoría de los pacientes [N=61(37%)] El derrame pleural fue el hallazgo radiológico más frecuente (37.6%). El signo más prevalente en la ecocardiografía fue la presencia de insuficiencia tricuspíde a (50.3%). La mortalidad en nuestra serie fue del 10.3%. CONCLUSIONES: El incremento en la edad de nuestros pacientes, los factores de riesgo asociados a la enfermedad tromboembólica, y las nuevas herramientas pronosticas, pueden facilitarnos el manejo de esta enfermedad que escasamente ha variado su morbimortalidad a pesar de los avances médicos

INTRODUCTION: Pulmonary thromboembolism (PTE) constitutes a health problem of great importance due to its high morbimortality. Venous thromboembolic disease (VTE) causes 300,000 hospitalizations a year, with an incidence from 0.5 to 2.5%among the patients admitted for medical pathology and from 0.1 to0.6% of those admitted for surgical causes. The prevalence among admissions is approximately 1%.OBJECTIVE: To study the characteristics of the patients admitted for PTE in our hospital area in order to be able to evaluate the epidemiology, the risk factors and the evolution during the acute period. PATIENTS AND METHOD: We studied all patients who were admitted to the University Hospitals Virgen del Rocio of Seville in the period included from February 2003 to September 2004 and diagnosed with PTE. Clinical data, diagnoses, and evolutions were systematically collected until the hospital discharge. Troponin and BNP (brain natriuretic peptide) levels in blood were determined, and echocardiography was performed, in the first 48 h after admission. RESULTS: During 19 consecutive months a total of 456patients entered our hospital area with suspicion of PTE. Of these, this diagnosis was confirmed in only 165 cases (36%). Eighty two(49.7%) were women and eighty three (50.3%) were men. The average age was 64.47±16.77. The risk factor for VTE presented with more frequency was immobilisation secondary to admission. The symptoms presented more frequently were dyspnoea and thoracic pain. The electrocardiogram was normal in most of the patients [N=61 (37%). Pleural effusion was the more frequent radiological finding (37.6%). The more prevalent sign in the echocardiography was the presence of tricuspid insufficiency (50.3%). Mortality in our series was 10.3%.CONCLUSIONS: The increase in the age of our patients, the risk factors associated to thromboembolic disease mainly in hospitalized patients, and the new prognostic tools, can facilitate our handling of this disease that has barely varied its morbimortality in spite of the technological advances

Tendencias divergentes en la mortalidad por cáncer de próstata en la Comunidad Autónoma de Andalucía (1975-2004) / Diverging trends in prostate cancer mortallity in the autonomous community of Andalucia (1975-2004)

Objetivo. Describir la evolución de la mortalidad por cáncer de próstata en Andalucía durante el periodo 1975-2004 a nivel provincial. Sujetos y método. Los datos de mortalidad por cáncer de próstata y las poblaciones necesarias para el cálculo de los indicadores fueron facilitados por el Instituto de Estadísticas de Andalucía. Se calcularon las tasas especificas por grupos de edad y estandarizadas globales y truncadas (35-64 años) mediante el método directo (población estándar europea). Resultados. En el año 2004 se produjeron en Andalucía 813 defunciones por cáncer de próstata, representando el 8% de la mortalidad por tumores. El análisis 'joinpoint' permite delimitar tres tendencias diferenciadas en los últimos años (descenso en Cádiz, Huelva y Málaga, incremento en Granada y estabilización en el resto de provincias) en las tasas ajustadas de mortalidad por cáncer de próstata. Conclusión. En Granada, en contra de la tendencia observada en el resto de provincias de Andalucía, se está produciendo un incremento en la mortalidad por cáncer de próstata

Objective. To describe the evolution of prostate cancer mortality in Andalucia during the period 1975-2004 at the provincial level. Subjects and method. Mortality data for prostate cancer and population denominator data was supplied by the Statistical Institute of Andalucia. Age group-specific and standardised overall and truncated (50-79 years old) rates were calculated by the direct method (European standard population). Results. In 2004 there were 813 deaths in Andalucia from prostate cancer. Prostate cancer accounts for around 8% of male deaths from cancer. Joinpoint analysis shows three diverging trends (fall in Cadiz, Huelva and Malaga, rise in Granada and stabilization in the other provinces) in age-standardized mortality rates. Conclusion. In Granada, an increment in mortality from prostate cancer is observed in opposition to the trend in the other provinces

[High-frequency oscillatory ventilation. A single-center study]. / Nuestra experiencia con la ventilación de alta frecuencia oscilatoria.

INTRODUCTION: High-frequency oscillatory ventilation is a safe and effective means of delivering mechanical ventilatory support. OBJECTIVE: To evaluate the safety and effectiveness of high-frequency oscillatory ventilation in pediatric patients with acute respiratory failure. PATIENTS AND METHOD: From August 2003 to July 2005, we performed a prospective observational study of 11 children older than 1 month who underwent high-frequency oscillatory ventilation. Pediatric risk of mortality scores (PRISM), Murray lung-injury scores and air leak scores were recorded at baseline before ventilation. The following variables were studied: ventilatory settings (FiO2 and mean airway pressure), gasometric (PaO2, SaO2, PaCO2, pHa, PaO2/FiO2 ratio) and hemodynamic parameters (Partm, PVC), and the oxygenation index. RESULTS: The overall survival rate was 82 %. Significant increases were found in PaO2 (p < 0.05), SaO2 (p < 0.05) and the PaO2/FiO2 ratio (p < 0.05), while mean airway pressure (p < 0.001), oxygenation index (p < 0.001), and FiO2 (p < 0.001) significantly decreased over time. CONCLUSIONS: High-frequency oscillatory ventilation significantly improved oxygenation in children with acute hypoxemic respiratory failure.

[Renal oncocytoma. Review of our 22 patients]. / Oncocitoma renal. Revisión de nuestra serie de 22 pacientes.

UNLABELLED: Renal oncocytoma (OR) is a benign tumor. It may represent up to 3-7% of solid kidney masses, and shows specifics cellular and evolutive characteristics. Metacronicity, multifocality and bilateralism has been reported. MATERIALS AND METHODS: Between 1986 and 2005, 478 kidney tumors have been surgically treated at our institution. We report the frequency and characteristics of OR in our patients, compared with renal cell carcinomas (RCC). We try to find out the rate of multifocality, bilateralism and other tumor association, and the number of neoplasms originally diagnosed as OR before surgery. Mean and median follow up: 36.86 and 13 months (1-193). Specific survival rate 100%. RESULTS: We found 24 OR in 10 men and 12 women with a mean age of 59 years (34-84). 12 in the left kidney and 12 in the right one, one patient presenting oncocytomatosis. Tumor mean size was 4.64 cm (1-12.5 cm). Tumors were discovered incidentally in 17 cases. Presentation symptoms in the rest of patients were gross hematuria. CONCLUSIONS: The rate of OR found in our sample population of renal tumors undergoing surgery matches other series already published. Two synchronic OR, but not metacronous, bilateral or metastatic tumors were found. All cases presented a benign evolution.