Analysis of Intrahospital Mortality in Patients With Lung Transplant Due to Diffuse Parenchymal Lung Disease.

BACKGROUND: Patients with diffuse parenchymal lung disease (DPLD) have the poorest survival rates both before and after lung transplantation (LT). Early mortality among LT patients as a result of DLPD is estimated at 10% to 20%. The aim of the study was to assess intrahospital mortality after LT procedures for DLPD and to identify factors in the recipient, donor, intra- and postoperative periods that might improve early outcomes. METHODS: A retrospective, observational, cohort, single-hospital study was conducted. Data from 67 patients with LT patients owing to DPLD were recorded between October 2008 to June 2017 in Madrid, Spain. RESULTS: Out of 67 LT recipients with DPLD, 51 had idiopathic pulmonary fibrosis (IPF)/usual interstitial pneumonia (UIP), 6 nonspecific interstitial pneumonia (NSIP), and 10 other DPLD. Intrahospital mortality took place in 13.4% of patients, with a median survival time of 34 days (interquartile range [IQR], 27.50-66). In the preoperative period, there were no differences in the recipients' demographic and hemodynamic characteristics, respiratory function, or time spent in the waiting list, except higher doses of systemic steroids in nonsurvivors (prednisone 15 vs 10 mg, P = .046). No differences were reported in the donors' characteristics (age, mechanical ventilation hours, PaO2/FiO2). In the intraoperative and postoperative periods, we found differences statistically significant in longer cold ischemia time and development of primary graft dysfunction (PGD) grade 3 in the nonsurvivor group. CONCLUSIONS: The mortality rate in our series was 13.4%, and the main risk factors for intrahospital mortality were longer cold ischemia time and greater incidence of PGD grade 3.

Influence of Pulmonary Hypertension on Intrahospital Mortality in Lung Transplantation for Interstitial Lung Disease.

BACKGROUND: Pulmonary hypertension (PH) is a comorbidity associated with interstitial lung disease (ILD). The purpose of this study was to evaluate the influence of PH on intrahospital mortality in lung transplantation (LT) for ILD. METHODS: We conducted a retrospective cohort study of 66 patients who underwent LT for ILD at the 12 de Octubre University Hospital (Madrid, Spain) from October 2008 to June 2014. PH was defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg on right-sided heart catheterization and intrahospital mortality as any death taken place after the transplantation of patients not being discharged. RESULTS: We retrospectively analyzed data of 66 patients; they were stratified by the presence or absence of PH before LT. Twenty-seven patients (41%) had PH. The PH group had a lower diffusing capacity of carbon monoxide (DLCO), carbon monoxide transfer coefficient (KCO), and 6-minute walk distance test (6MWT) and a higher total lung capacity (TLC), modified medical research council dyspnea scale (mMRC), and lung allocation score (LAS) than the non-PH group. Patients with PH more often underwent double lung transplantation (DLT; 59%) than single lung transplantation (SLT). Intrahospital mortality was 13% (9/66). No significant differences were observed in Kaplan-Meier survival curves for the PH and non-PH groups with a median survival time of 46 days versus 33 days (IQR 26-74; log-rank P = .056); however, the postoperative length of stay in the hospital was greater in the PH group. CONCLUSIONS: In our cohort, pulmonary hypertension was not related to early mortality in lung transplantation recipients for interstitial lung diseases.

Situación actual de la rehabilitación respiratoria en los hospitales de la Comunidad de Madrid / No disponible

Introducción: A pesar de que la rehabilitación respiratoria (RR) es considerada como una intervención terapéutica con alto nivel de evidencia científica, la estructura y la organización de las unidades de RR pueden repercutir en sus resultados. Nuestra intención era conocer la situación actual de las unidades de RR de la Comunidad de Madrid. Material y métodos: Análisis de los resultados de la encuesta distribuida a todos los hospitales de la Comunidad de Madrid mediante correo electrónico desde la Sociedad Madrileña de Neumología y Cirugía Torácica (NEUMOMADRID) y la Sociedad Española de Rehabilitación Cardiorrespiratoria (SORECAR). La encuesta fue diseñada de acuerdo a los estándares de calidad asistencial en RR propuestos por la Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Resultados: Once (61,6%) hospitales señalaron que contaban con una unidad de RR y en el 54,5% de ellas no existía acceso desde atención primaria. El 72,7% de unidades indicó que la derivación de pacientes no era adecuada. Casi todas las unidades ofrecían programas de fisioterapia, entrenamiento aeróbico, de fuerza muscular y soporte educativo, sin embargo solo el 27,3% daba soporte nutricional y 18,2% apoyo psicosocial. El 45,4% usaba la prueba de esfuerzo progresivo para pautar el entrenamiento. Existían 3 cicloergómetros (rango intercuartílico 2-5) y 1 tapiz rodante (0-2) por unidad. Todas las unidades contaba con médicos rehabilitadores y fisioterapeutas y en el 60% también participaban neumólogos. Conclusiones: No todos los hospitales de la Comunidad de Madrid cuentan con unidades de RR. Además, el análisis de los indicadores de calidad asistencial en RR demuestran limitaciones en protocolos, evaluación del paciente, componentes y características de los programas, y aspectos administrativos y de investigación

Introduction: Although respiratory rehabilitation (RR) is considered as a therapeutic intervention with a high level of scientific evidence, the structure and organization of the RR units may have repercussions on its results. Our intention was to know the current situation of RR units in the Community of Madrid. Material and Methods: Analysis of results of the survey distributed to all hospitals in the Community of Madrid by email from the Sociedad Madrileña de Neumología y Cirugía Torácica (NEUMOMADRID) and the Sociedad Española de Rehabilitación Cardiorrespiratoria (SORECAR). The survey was designed according to the standards of care quality in RR proposed by the Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Results: 11 (61.6%) hospitals reported that they had a RR unit. 54.5% of them did not have an access from primary care. 72.7% of the units indicated that referral of patients was not adequate. Almost all the units offered programs of physical therapy, aerobic training, muscular strength and educational support, however only 27.3% gave nutritional support and 18.2% psychosocial support. Progressive incremental test was used by 45.4% RR units. There were 3 cycle ergometers (interquartile range 2-5) and 1 treadmill (0-2) per unit. All units had rehabilitation physicians and physiotherapists, and 60% also had pulmonologists. Conclusions: Not all hospitals in the Community of Madrid have RR units. Moreover, the analysis of the indicators of care quality of the RR shows limitations in protocols, patient evaluation, components and characteristics of the programs, administrative and research aspects

Detection of Epstein-Barr virus DNAemia after lung transplantation and its potential relationship with the development of post-transplant complications.

BACKGROUND: Recent studies suggest that Epstein-Barr virus DNAemia (EBVd) may act as a surrogate marker of post-transplant immunosuppression. This hypothesis has not been tested so far in lung transplant (LT) recipients. METHODS: We included 63 patients undergoing lung transplantation at our center between October 2008 and May 2013. Whole blood EBVd was systematically assessed by real-time polymerase chain reaction assay on a quarterly basis. The occurrence of late complications (overall and opportunistic infection [OI] and chronic lung allograft dysfunction [CLAD]) was analyzed according to the detection of EBVd within the first 6 months post transplantation. RESULTS: Any EBVd was detected in 30 (47.6%) patients. Peak EBVd was higher in patients with late overall infection (2.23 vs. 1.73 log10 copies/mL; P = 0.026) and late OI (2.39 vs. 1.74 log10 copies/mL; P = 0.004). The areas under receiver operating characteristic curves for predicting both events were 0.806 and 0.871 respectively. The presence of an EBVd ≥2 log10 copies/mL during the first 6 months post transplantation was associated with a higher risk of late OI (adjusted hazard ratio [aHR] 7.92; 95% confidence interval [CI] 2.10-29.85; P = 0.002). Patients with detectable EBVd during the first 6 months also had lower CLAD-free survival (P = 0.035), although this association did not remain statistically significant in the multivariate analysis (aHR 1.26; 95% CI 0.87-5.29; P = 0.099). CONCLUSIONS: Although preliminary in nature, our results suggest that the detection of EBVd within the first 6 months after transplantation is associated with the subsequent occurrence of late OI in LT recipients.

An electric stimulation system for electrokinetic particle manipulation in microfluidic devices.

Microfluidic devices have grown significantly in the number of applications. Microfabrication techniques have evolved considerably; however, electric stimulation systems for microdevices have not advanced at the same pace. Electric stimulation of micro-fluidic devices is an important element in particle manipulation research. A flexible stimulation instrument is desired to perform configurable, repeatable, automated, and reliable experiments by allowing users to select the stimulation parameters. The instrument presented here is a configurable and programmable stimulation system for electrokinetic-driven microfluidic devices; it consists of a processor, a memory system, and a user interface to deliver several types of waveforms and stimulation patterns. It has been designed to be a flexible, highly configurable, low power instrument capable of delivering sine, triangle, and sawtooth waveforms with one single frequency or two superimposed frequencies ranging from 0.01 Hz to 40 kHz, and an output voltage of up to 30 Vpp. A specific stimulation pattern can be delivered over a single time period or as a sequence of different signals for different time periods. This stimulation system can be applied as a research tool where manipulation of particles suspended in liquid media is involved, such as biology, medicine, environment, embryology, and genetics. This system has the potential to lead to new schemes for laboratory procedures by allowing application specific and user defined electric stimulation. The development of this device is a step towards portable and programmable instrumentation for electric stimulation on electrokinetic-based microfluidic devices, which are meant to be integrated with lab-on-a-chip devices.

Infartos pulmonares bilaterales complicados por Staphylococcus warnerii / Bilateral pulmonary infarction complicated by Staphylococcus warnerii

El infarto pulmonar es una complicación que aparece entre un 10-15% de los embolismos pulmonares. Un 5-10% deestos infartos se cavitan secundariamente. El cuadro clínico suele cursar con dolor pleurítico intenso, fiebre y en el 30% de los casos se acompaña de hemoptisis. El diagnóstico diferencial, basado en los hallazgos radiológicos, debe establecerseesencialmente con la tuberculosis pulmonar, el absceso pulmonar y el embolismo séptico. Presentamos el caso deun paciente con infartos pulmonares bilaterales secundariamente complicados por Staphylococcus warnerii

Lung infarction is a frequent complication in about 10-15% of pulmonary embolism. Approximately 5-10% of lunginfarctions are secondarily cavitated. Chest pain and fever are the most frequent symptoms and about 30% of them have haemoptysis. Differential diagnosis based on radiologic findings would be established with pulmonary tuberculosis, lung abscess and septic embolism. We describe the clinical case of a patient with bilateral lung infarction secondarily Staphylococcus warnerii infection

[Lymphoid interstitial pneumonia resolved through antiretroviral therapy in an adult infected by human immunodeficiency virus]. / Neumonía intersticial linfoidea en un paciente adulto con infección por el VIH, resuelta con tratamiento antirretroviral.

Lymphoid interstitial pneumonia (LIP) is a rare entity characterized by the infiltration of interstitial tissues and alveolar spaces by lymphocytes, plasma cells, and other lymphoreticular structures. The etiology of LIP is unknown, although associations with autoimmune and infectious factors have been described. The incidence of LIP has risen in recent years, mainly in children with acquired immunodeficiency syndrome (AIDS), while remaining less common in the adult population. No agreement has been reached regarding the diagnostic tests necessary for a firm diagnosis although suspicion is usually based on clinical and radiographic findings, with confirmation provided by examination of histological samples. The most common treatment is corticosteroids, either alone or in combination with other immunosuppressant agents although no evidence from controlled trials is available and cases have been reported in which LIP resolved in AIDS patients with antiretroviral therapy alone. We report the case of a human immunodeficiency virus-infected adult who was diagnosed with LIP by open lung biopsy and who responded to antiretroviral drugs with no need for associated corticosteroid therapy.

[Mechanical ventilation in a respiratory ward. Evolution from 1994 to 2000]. / Ventilación mecánica en hospitalización neumológica. Evolución en el período 1994-2000.

OBJECTIVE: To investigate the absolute and relative frequency of mechanical ventilation in the management of patients on a respiratory medicine ward between 1994 and 2000. To describe reasons for admission, mean hospital stay and outcomes. SETTING: A tertiary-care university hospital. METHODS: Observational, descriptive study of a case series. RESULTS: During the study period, 257 admissions involved mechanical ventilation of 132 patients. During that time, there was a progressive increase in the total number of ventilated patients as well as in the relative frequency, such that ventilated patients eventually accounted for 6.1% of all admissions for respiratory care in 2000. Nearly 80% of admissions were related to the service's home mechanical ventilation program, either to initiate and adapt ventilation for new patients or to treat exacerbations or diagnose and treat other medical or surgical problems in already-ventilated patients. Patients transferred from the intensive care unit (ICU) because of weaning difficulties (median ventilation, 31 days) had the highest mean stay. Nine of the 132 patients had to be transferred to the ICU and 18 died while hospitalized (7% of admissions and 13.6% of patients). The patients who died were those who were more acutely and severely ill (acute exacerbation in home-ventilated patients, patients with acute respiratory failure treated initially with non-invasive ventilation and patients transferred from the ICU due to weaning difficulties). CONCLUSIONS: Admissions requiring mechanical ventilation have increased and most are related to the home mechanical ventilation program. The mean stay and the mortality rate were related to the reason for admission.

Ventilación mecánica en hospitalización neumológica. Evolución en el período 1994-2000 / Mechanical ventilation in a respiratory ward. Evolution from 1994 to 2000

OBJETIVO: Conocer la frecuencia absoluta y relativa de pacientes que han utilizado la ventilación mecánica como parte de su tratamiento en una sala de hospitalización neumológica en el período 1994-2000, describir las causas que han motivado la indicación y analizar su estancia media y sus resultados. ÁMBITO: Hospital terciario universitario. PACIENTES Y MÉTODOS: Estudio observacional descriptivo de serie de casos. RESULTADOS: En el período de estudio hubo 257 ingresos hospitalarios con ventilación mecánica en 132 pacientes. Durante ese tiempo se produjo un incremento progresivo en el número anual absoluto y relativo de pacientes que, en el año 2000, representó el 6,1 por ciento del total de las hospitalizaciones en la planta de neumología. Casi el 80 por ciento de los ingresos estaban relacionadas con el programa de ventilación mecánica domiciliaria, bien para inicio programado de adaptación a la misma, o estando en tratamiento previo con ella por agudización respiratoria o para el diagnóstico y tratamiento de otros problemas médicos o quirúrgicos. El grupo de mayor estancia media fue el de los pacientes trasladados desde la unidad de cuidados intensivos por ventilación mecánica prolongada (mediana de 31 días). Del total de pacientes (n = 132), nueve fueron trasladados a la unidad de cuidados intensivos y 18 fallecieron (el 7 por ciento del total de las hospitalizaciones y 13,6 por ciento de los pacientes).La mortalidad se concentró en los grupos con pacientes más agudos y graves: pacientes con ventilación mecánica domiciliaria previa y agudización respiratoria, pacientes con ventilación mecánica no invasiva para tratamiento de la insuficiencia respiratoria aguda y pacientes trasladados desde la UCI por ventilación mecánica prolongada y dificultades en la desconexión. CONCLUSIONES: Se ha producido un incremento progresivo del número de pacientes hospitalizados con ventilación mecánica, en la mayor parte de los casos relacionados con el programa de ventilación mecánica domiciliaria. La estancia media y la mortalidad dependieron del motivo de la ventilación mecánica (AU)

Estudio clínico y nasométrico de la función velofaríngea en dos tiempos / Clinico-nasometric study of the velopharyngeal function in the two-stage palatoplasty

En 1976 iniciamos un régimen de estafilorrafia en dos tiempos en pacientes con fisura labio-palatina completa, con veloplastia al año de edad y palatoplastia del paladar óseo entre 3-12 años de edad. El objetivo es presentar la valoración clínica e instrumental del habla y de la función velofaríngea de 41 pacientes, edad media 8,2 años, 28 fisurados unilaterales y 13 bilaterales; 7 casos presentaban fístula palatina > 5 mm2. Los resultados muestran hipernasalidad moderada-severa en 20 por ciento de los casos, errores articulatorios persistentes con posteriorización en 43 por ciento de los casos, golpe de glotis en 2 por ciento, la inteligibilidad era deficiente en 7 por ciento. La evaluación de la resonancia oro-nasal con el Nasometer muestra valores de sospecha o Insuficiencia velofaríngea (IVF) en 14 y 20 por ciento de los casos respectivamente. Por Nasofibroscopia el 35 por ciento mostró algún grado de IVF. El 17 por ciento requirió repalatoplastia o cierre de fístula y un 12 por ciento colgajo faríngeo. La gran incidencia de errores articulatorios nos ha obligado a discontinuar esta técnica (AU)

Since 1976 children born with complete cleft lip and palate have been treated according to two stage cleft palate repair regime, soft palate at one year of age and hard palate between 3-12 years of age. The objective of this paper is to present the clinical and instrumental speech evaluation and the velopharyngeal function of 41 patients, mean age 8.2 years, 28 unilaterals and 13 bilateral clefts; 7 cases had palatal fistulae larger than 5 mm2. The results showed moderate-severe hypernasality in 20% of cases, persisting articulatory errors with backing in 43% of cases, glotal stops in 2%, the intelligibility was deficient in 7%. The evaluation of the oro-nasal resonance with Nasometry showed suspicious or VPI values in 14 and 20% of cases respectively. Nasendoscopy findings showed same degree of VPI in 35% of cases. Repalatoplasty or fistula closure was needed in 17% and pharyngeal flap in 12% of cases. The great incidence of articulatory errors have promoted us to discontinue this technique (AU)

[Clinical and nasometric study of velopharyngeal function in two-stage palatoplasty]. / Estudio clínico y nasométrico de la función velofaríngea en la palatoplastia en dos tiempos.

Since 1976 children born with complete cleft lip and palate have been treated according to two stage cleft palate repair regime, soft palate at one year of age and hard palate between 3-12 years of age. The objective of this paper is to present the clinical and instrumental speech evaluation and the velopharyngeal function of 41 patients, mean age 8.2 years, 28 unilaterals and 13 bilateral clefts; 7 cases had palatal fistulae larger than 5 mm2. The results showed moderate-severe hypernasality in 20% of cases, persisting articulatory errors with backing in 43% of cases, glotal stops in 2%, the intelligibility was deficient in 7%. The evaluation of the oro-nasal resonance with Nasometry showed suspicious or VPI values in 14 and 20% of cases respectively. Nasendoscopy findings showed same degree of VPI in 35% of cases. Repalatoplasty or fistula closure was needed in 17% and pharyngeal flap in 12% of cases. The great incidence of articulatory errors have promoted us to discontinue this technique.

[Results of a questionnaire on the treatment of cleft lip and palate in Spain]. / Resultado de la encuesta sobre el tratamiento del fisurado labio-palatino en España.

OBJECTIVE: To present the results of a questionnaire done to evaluate the status of the multidisciplinary team treatment of cleft lip and palate in Spain, directed to know the experience and organization of each center. METHOD: A questionnaire was sent to 34 hospitals asking about the following: existence of multidisciplinary team, number of primary surgical cleft operation in 1997, specialty of the primary surgeon/s, the presence in the hospital staff of: ENT, speech therapist, orthodontist, maxillofacial surgeon; if evaluation of the velopharyngeal function is done, if orthodontist meets with other members of the team, where the speech therapy is performed, how the financial burden of these treatments are covered and if there is a parent group. RESULTS: Nineteen centers (55.8%) have responded. Only seven centers admit to have a multidisciplinary team, primary surgery is done by pediatric, plastic and maxillofacial surgeons, 36% of the surgeons operate less then 10 cases/year, the absence of a speech therapist and orthodontist in staff was 42% and 84% respectively, instrumental diagnosis of VPI is not performed in 60% of teams, scanty and not uniform cost coverage of these treatments, only 12% of centers admit to have a parent group. CONCLUSIONS: Deficiencies of organization and staff are present in many centers, there is not a team culture. Centralization of primary surgery is needed. The need of a Spanish Cleft Palate Association is pointed. Eurocleft treatment guidelines are presented.

[Integrated treatment of cleft lip and palate. Organization of a treatment team]. / Tratamiento integral de las fisuras labio palatinas. Organización de un equipo de tratamiento.

OBJECTIVE: Collect the team experience in the treatment of children with cleft lip and palate, indicating the evolution of the team composition, advantages and improvement aspects, trying to transmit the need of team treatment. METHOD: The Bilbao cleft palate team was created in 1983, since then a cleft palate clinic, a parents group and a unit of velopharyngeal function has been developed. At present the team is composed by: pediatric reconstructor surgeon, speech therapist, orthodontist, dentist, pediatrician, ENT, maxillofacial surgeon, dismorphologyst, geneticist, nursing. RESULTS: One of the achievements has been the data unification, obtaining speech cephalometrics, photographic dental casts and video images with prospective view. At this time 403 cleft lip and palate children have been intervened, being essential the transdisciplinar team approach between surgeon, speech therapist and orthodontist. The importance of the team coordinator is pointed. The results of an audit of the two stage cleft palate closure in complete unilateral cleft lip and palate have obligated us to vary our surgical policy. The unresolved aspects are the lack of multidisciplinary team recognition at official level and the non existence of orthodontist in staff, without cost coverage of this treatment by public health system. CONCLUSIONS: In our experience the team treatment of cleft lip and palate has resulted in improvement of the clinic results, treatment protocols and training.

[Section of the sublingual frenulum. Are the indications correct?]. / Sección del frenillo sublingual. Son las indicaciones correctas?

OBJECTIVE: To see the relationship of the lingual frenum with speech and other oral functions, evaluating the surgical indications and the results of frenectomy. MATERIAL AND METHODS: In 1997 we operated 72 children with sublingual frenulum, a telephone questionnaire to the mothers of these patients was done, obtaining data about: age at surgery, professional reasons for referral, preoperative findings, pre-post operative speech therapy, place of surgery and type of anesthesia and mother's impression about the final result. RESULTS: Fifty valid questionnaires were obtained, the mean age at frenectomy was 3.03 years, 38% of children were sent due to speech problems, 60% due to some degree of tongue-tie and 2% due to dentofacial developmental anomalies. In 70% the patients were sent by a pediatrician and in 14% by a speech therapist. In 20% preoperative speech therapy was done and postoperatively in 30%. In 48% of cases, aged less than 2 years, speech was not possible to be evaluated. In the 11 cases with questionable results, a multidisciplinary reevaluation showed 7 cases with lingual dysfunction and poor tongue control, 4 cases with deglutitory anomalies and 3 cases with orofacial occlusal problems secondary to lingual dysfunction or altered oral habits. CONCLUSIONS: The presence of a nondisturbing lingual frenulum does not justify its surgical section, the frenectomy is indicated only in presence of altered oro-lingual functions caused by the tongue-tie such as: speech problems, errors of bite and deglutition, lingual dysfunction and anomalous oral habits.