Risk scores' performance and their impact on operative decision-making in left-sided endocarditis: a cohort study.

The accuracy of contemporary risk scores in predicting perioperative mortality in infective endocarditis (IE) remains controversial. The aim is to evaluate the performance of existent mortality risk scores for cardiovascular surgery in IE and the impact on operability at high-risk thresholds. A single-center retrospective review of adult patients diagnosed with acute left-sided IE undergoing surgery from May 2014 to August 2019 (n = 142) was done. Individualized risk calculation was obtained according to the available mortality risk scores: EuroScore I and II, PALSUSE, Risk-E, Costa, De Feo-Cotrufo, AEPEI, STS-risk, STS-IE, APORTEI, and ICE-PCS scores. A cross-validation analysis was performed on the score with the best area under the curve (AUC). The 30-day survival was 96.5% (95%CI 91-98%). The score with worse area under the curve (AUC = 0.6) was the STS-IE score, while the higher was for the RISK-E score (AUC = 0.89). The AUC of the majority of risk scores suggested acceptable performance; however, statistically significant differences in expected versus observed mortalities were common. The cross-validation analysis showed that a large number of survivors (> 75%) would not have been operated if arbitrary high-risk threshold estimates had been used to deny surgery. The observed mortality in our cohort is significantly lower than is predicted by contemporary risk scores. Despite the reasonable numeric performance of the analyzed scores, their utility in judging the operability of a given patient remains questionable, as demonstrated in the cross-validation analysis. Future guidelines may advise that denial of surgery should only follow a highly experienced Endocarditis Team evaluation.

Echocardiography and FDG-PET/CT scan in Gram-negative bacteremia and cardiovascular infections.

PURPOSE OF REVIEW: Current evidence on cardiovascular infections in Gram-negative blood stream infections (GNBSI) with focus on the use of transesophageal echocardiography (TEE) and 18F-Fluorodeoxyglucose - positron emission tomography/Computed tomography (FDG-PET/CT) in the diagnostic workup. RECENT FINDINGS: Most evidence focuses on characteristics of diagnosed cardiovascular infections and the proportion caused by GNBSI. These proportions are low (1-5%) when it comes to native and prosthetic valve endocarditis as well as cardiac implantable electronic device (CIED) infections whereas the proportion of vascular graft infections caused by GNBSI seems substantially higher (30-40%). Information on the prevalence of cardiovascular infection in patients with GNBSI is limited to a few studies finding around 3% endocarditis in patients with GNBSI and a prosthetic heart valve and 4-16% device-related infection in patients with CIED and GNBSI. SUMMARY: Patients with GNBSI and native or prosthetic valves should only undergo work-up for endocarditis (TEE and FDG-PET/CT) if they present GNBSI relapse or signs suggestive of endocarditis. CIED patients with GNBSI with Pseudomonas or Serratia spp. should undergo TEE and PET/CT because of the high prevalence of device-related infection. In other GNBs without IE suggestive signs, normal BSI treatment is reasonable and only cases with relapse need work-up. GNBSI in patients with vascular grafts should lead to consideration of PET/CT.

Implementation of Alere i Influenza A & B point of care test for the diagnosis of influenza in an ED.

STUDY OBJECTIVE: This study aimed to evaluate the impact of implementing rapid point-of-care testing (POCT) with the Alere i Influenza A & B in an emergency department (ED) during an influenza epidemic. METHODS: Direct nasal swabs were prospectively collected following the physical examination of patients aged >18years who presented to the ED of a tertiary hospital in France with influenza-like illness (ILI) symptoms (N=301) between February 1st and March 31st, 2016, which coincided with an influenza epidemic. Laboratory-based testing (standard of care) was used to obtain a diagnosis in February 2016 (pre-POCT cohort) and positive results were confirmed using polymerase chain reaction. The primary endpoint was patient time in the ED. RESULTS: A total of 169 and 132 patients participated in the pre-POCT phase and POCT phase respectively. A significantly higher proportion of patients received a positive diagnosis in the POCT cohort compared with the pre-POCT cohort (31% versus 5.3%, P<0.01). Mean time spent in the ED and hospitalization rate were significantly lower in the POCT cohort (6.06h versus 4.15h, P=0.03, and 44.4% versus 9.7%, P=0.02, respectively). Despite similar rates in the prescription of antibiotics and antiviral therapies, the proportion of patients who were referred for additional tests was significantly lower in the POCT cohort (78.1% versus 62.1%, P=0.003, and 80.5% versus 63.6%, P=0.01, respectively). CONCLUSIONS: The Alere i Influenza A & B POCT reduced the length of stay in ED, the hospitalization rates, and the number of additional diagnostic tests compared with standard of care testing.

Analysis of the THz response of a simple periodic graphite-based structure.

We report the observation of the dichroism effect in simple wire grid structures made of graphite on a paper substrate, i.e. we investigate the feasibility of drawing polarizers for the THz band using conventional graphite-based lead pencils. The displacement of the maximum frequency of the selective absorption phenomenon by varying the wire pitch hints at a polarizing behavior. Measurements of the maximum and minimum of transmission efficiency, extinction ratio and degree of polarization are carried out with a transmission fiber THz-TDS setup. Experimental results show a 9 dB extinction ratio for an inexpensive (<1$) home-made component.

[Extravasation of contrast media at the puncture site: Strategies for managment]. / Extravasación de medios de contraste intravenosos en el sitio de la punción: Protocolo de actuación.

The incidence of contrast medium extravasation at the venipuncture site has increased with the generalized use of automatic injectors. Most extravasations only cause slight edema and erythema. Nevertheless, in some cases extravasation can result in severe skin lesions or even in compartment syndrome. Lesions caused by extravasation usually resolve spontaneously with conservative treatment. Although the complications of extravasation are well known, institutional protocols are normally lacking and the criteria for taking action and the type of treatment, whether based on the literature or personal preferences, tend to vary. In this article, we review the incidence, risk factors, clinical manifestations, and options for preventing and treating contrast medium extravasation in soft tissues. Finally, we present the protocol we use to manage extravasation at our hospital.

High NaCl concentrations induce the nod genes of Rhizobium tropici CIAT899 in the absence of flavonoid inducers.

The nodulation (nod) genes of Rhizobium tropici CIAT899 can be induced by very low concentrations (micromolar to nanomolar range) of several flavonoid molecules secreted by the roots of leguminous plants under a number of different conditions. Some of these conditions have been investigated and appear to have a great influence on the concentration and the number of different Nod factors, which can induce root nodule primordia and pseudonodules in several leguminous plant roots. In one such condition, we added up to 300 mM NaCl to the induction medium of R. tropici CIAT899 containing the nod gene inducer apigenin. At the higher concentrations of NaCl, larger amounts and more different Nod factors were produced than in the absence of extra NaCl. To our surprise, under control conditions (300 mM NaCl without apigenin), some Nod-factor-like spots were also observed on the thin-layer plates used to detect incorporation of radiolabeled glucosamine into newly synthesized Nod factors. This phenomenon was further investigated with thin-layer plates, fusions of nod genes to the lacZ gene, high-performance liquid chromatography, mass spectrometry, and the formation of pseudonodules on bean roots. Here, we report that, in the absence of flavonoid inducers, high concentrations of NaCl induced nod genes and the production of Nod factors.

Control of terahertz emission in photoconductive antennas through an additional optical continuous wave.

The manipulation of the operating conditions of photoconductive antennas by means of an additional continuous wave (CW) is reported. It is used to control a fiber-based terahertz (THz) time-domain-spectroscopy system at telecom wavelengths. The injection of an optical CW into the transmitter allows the control of the THz amplitude without causing major degradation to the system performance. This, for instance, can be exploited to perform modulation of the THz signal.

Comparative study of mechanical vs. manual circumcision in the pediatric population: An alternative to the conventional technique? / Estudio comparativo entre circuncisión mecánica y manual en población pediátrica: ¿una alternativa a la técnica convencional?

OBJECTIVE: Circumcision is one of the most common surgical procedures in pediatric surgery. Even though manual suture (MANS) is regarded as the gold standard technique, easy-to-use mechanical suture (MECS) devices have been recently developed, with better postoperative results in the adult population. The objective of our study was to compare the operating time and incidence of postoperative complications between both techniques in our environment. MATERIALS AND METHODS: A retrospective study of patients undergoing circumcision in our institution from October 2021 to December 2022 was carried out. Operating time and complications observed in the first 14 postoperative days (edema, hematoma, dehiscence) were analyzed according to the technique used (MANS vs. MECS) and patient age (< 12 and ≥ 12 years old). RESULTS: 173 patients (147 MANS, 26 MECS) were included. Mean operating time was significantly lower in MECS patients, both in patients < 12 years old (16 min vs. 10 min, p= 0.002) and in patients ≥ 12 years old (23 min vs. 12 min, p< 0.001). Regarding complications, MECS patients ≥ 12 years old had a lower rate of suture dehiscence (23.5% vs. 0%, p< 0.001), with no significant differences in the younger group. CONCLUSIONS: MECS circumcision is a simple and effective technique involving shorter operating times than MANS circumcision, regardless of age. It has a lower rate of complications in older children (≥ 12 years), which means it stands as a valid alternative to the conventional technique.

OBJETIVOS: La circuncisión es una de las intervenciones quirúrgicas más realizadas en cirugía pediátrica. Aunque la técnica con sutura manual (SMAN) se considera el gold standard, recientemente se han desarrollado dispositivos de sutura mecánica (SMEC) de fácil manejo y con mejores resultados postoperatorios en la población adulta. El objetivo de nuestro estudio es comparar el tiempo quirúrgico y la incidencia de complicaciones postoperatorias entre ambas técnicas en nuestro ámbito. MATERIAL Y METODOS: Estudio retrospectivo de pacientes circuncidados en nuestro centro entre octubre 2021 y diciembre 2022. Se analizó el tiempo quirúrgico y las complicaciones observadas en los primeros 14 días postoperatorios (edema, hematoma, dehiscencia), en función de la técnica empleada (SMAN vs SMEC) y la edad de los pacientes (< 12 y ≥ 12 años). RESULTADOS: Se incluyeron 173 pacientes (147 SMAN, 26 SMEC). El tiempo quirúrgico medio fue significativamente menor en los pacientes con SMEC, tanto en < 12 años (16 min vs. 10 min, p= 0,002) como en ≥ 12 años (23 min vs 12 min, p< 0,001). En cuanto a las complicaciones, los pacientes con SMEC del grupo ≥ 12 años presentaron menor tasa de dehiscencia de sutura (23,5% vs 0%, p< 0,001), sin observarse diferencias significativas en el grupo de menor edad. CONCLUSIONES: La circuncisión con SMEC es una técnica sencilla y eficaz, que precisa un tiempo quirúrgico más reducido que la sutura manual, independientemente de la edad. Presenta menor tasa de complicaciones en los niños de mayor edad (≥ 12 años), por lo que se plantea como una alternativa válida a la técnica clásica.

[Antimicrobial stewardship program in an Intensive Care Unit: A retrospective observational analysis of the results 15 months after its implementation]. / Programa de optimización del uso de antimicrobianos en un Servicio de Medicina Intensiva: análisis retrospectivo observacional de los resultados 15 meses después de su implementación.

OBJECTIVE: We aim to evaluate the adherence rate to an Antimicrobial Stewardship Program (ASP) in an Intensive Care Unit (ICU), and to assess its effect on the use of antibiotics, quality indicators and clinical outcomes. METHODS: Retrospective description of the interventions proposed by the ASP. We compared antimicrobial use, quality and safety indicators in an ASP versus a non-ASP period. The study was performed in a polyvalent ICU of a medium-size University Hospital (600 beds). We studied patients admitted to the ICU for any cause during the ASP period, provided that a microbiological sample aiming to diagnose a potential infection has been drawn, or antibiotics have been started. We elaborated and registered of non-mandatory recommendations to improve antimicrobial prescription (audit and feedback structure) and its registry during the ASP period (15 months, October 2018-December 2019). We compared indicators in a period with ASP (April-June 2019) and without ASP (April-June 2018). RESULTS: We issued 241 recommendations on 117 patients, 67% of them classified as de-escalation type. The rate of adherence to the recommendations was high (96.3%). In the ASP period, the mean number of antibiotics per patient (3.3±4.1 vs 2.4±1.7, p=0.04) and the days of treatment (155 DOT/100 PD vs 94 DOT/100 PD, p <0.01) were reduced. The implementation of the ASP did not compromise patient safety or produce changes in clinical outcomes. CONCLUSIONS: The implementation of an ASP is widely accepted in the ICU, reducing the consumption of antimicrobials, without compromising patient safety.

Recommendations for the prevention of healthcare-associated infections in nursing homes.

Nursing homes (NH) conceptually should look as much like a home as possible. However NH have unquestionable similarities with a nosocomium as they are places where many patients with underlying diseases and comorbidities accumulate. There is evidence of transmission of microorganisms between residents and between residents and caregivers. We have not found any recommendations specifically aimed at the prevention of nosocomial infections in NH by the major Public Health Agencies and, therefore, the Health Sciences Foundation (Fundación de Ciencias de la Salud) has convened a series of experts and 14 Spanish scientific societies to discuss recommendations that could guide NH personnel in establishing written programs for the control and reduction of these infections. The present document is the result of these deliberations and contains suggestions for establishing such control programs on a voluntary and flexible basis in NH. We also hope that the document can help the health authorities to encourage this control activity in the different territorial areas of Spain. In our opinion, it is necessary to draw up a written plan and establish the figure of a coordinator or person responsible for implementing these projects. The document includes measures to be implemented and ways of quantifying the reality of different problems and of monitoring the impact of the measures established.

Photonic millimeter-wave frequency multiplication based on cascaded four-wave mixing and polarization pulling.

A technique for the frequency multiplication of microwave signals based on the combination of two optical nonlinear phenomena in a single nonlinear fiber is investigated. Multiple four-wave mixing is used to generate harmonics on an externally modulated optical carrier while polarization pulling through stimulated Brillouin scattering is used to filter the desired harmonics. Microwave signals in the 60 GHz region are generated showing harmonic frequency multiplication factors of up to 25 with a suppression of undesired harmonics better than 20 dB.

Long-term cardiac assessment in a sample of adolescent-onset anorexia nervosa.

BACKGROUND: High mortality rates have been reported in patients with anorexia nervosa, mainly due to cardiovascular alterations. The purpose of the present study was to assess cardiac structural and functional abnormalities some 20 years after initial treatment in a sample of adolescent-onset anorexia nervosa (A-AN) and to compare them with matched healthy controls (HC). METHODS: A sample of 29 women diagnosed and treated for AN during adolescence (A-AN) were assessed more than 20 years later. A complete cardiac evaluation was carried out including an electrocardiogram (ECG) and a standard 2D echocardiography. Thirty matched HC were also assessed. RESULTS: In the A-AN group, four subjects had a body mass index lower than 18.5 and met full DSM 5 criteria for AN at follow-up (Low-Weight group). They were compared with the rest of the sample (n = 25) who had normalized their weight (Normal-Weight group), though some still showed some eating disorder symptoms. Both groups were compared with the HC group. Subjects in the Low-Weight group presented statistically significant decreases in the left ventricular end-diastolic and left atrium dimensions and left ventricular mass in comparison with the Normal-Weight group and the HC. No other differences in cardiac parameters were found between groups. CONCLUSIONS: Echocardiographic and ECG parameters of adults who had presented A-AN twenty years earlier and currently maintained normal weight were similar to those of HC who had never been treated or diagnosed with AN. Adult subjects with A-AN who still had low weight in the long term present certain cardiac abnormalities similar to those seen in short-lasting disease. More studies are needed to confirm these results in a larger sample.

Anorexia nervosa is associated with multiple medical complications and high mortality, mainly due to cardiovascular complications. The main objective of the project was to study long-term cardiac abnormalities in a group of patients diagnosed with anorexia nervosa during adolescence. A sample of 29 patients, treated during adolescence for anorexia nervosa, were evaluated 20 years later. We did an echocardiogram and an electrocardiogram to all of them, and compared them with 30 healthy controls. Of the 29 patients with anorexia nervosa, 4 had low weight and 25 had normal weight. Patients who had normalized their weight did not present cardiac alterations and did not differ from the healthy controls. The 4 underweight patients did present cardiac abnormalities similar to those observed in short-term studies, such as decreased dimensions and mass of the left ventricle and the left atrium.

ADENI-UCI study: Analysis of non-income decisions in ICU as a measure of limitation of life support treatments.

OBJECTIVE: To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure. DESIGN: Prospective, multicentrico. SCOPE: 62 ICU from Spain between February 2018 and March 2019. PATIENTS: Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure. INTERVENTIONS: None. MAIN INTEREST VARIABLES: Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge. RESULTS: A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99). CONCLUSIONS: Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death.

Usefulness of transoesophageal echocardiography before circumferential pulmonary vein ablation in patients with atrial fibrillation: is it really mandatory?

AIMS: Transoesophageal echocardiography (TEE) is recommended prior to circumferential pulmonary vein ablation (CPVA) in patients with atrial fibrillation (AF) to identify left atrial (LA) or left atrial appendage (LAA) wall thrombi. It is not clear whether all patients undergoing CPVA should receive pre-procedural TEE. We wanted to assess the incidence of LA thrombus in these patients and to identify factors associated with its presence. METHODS AND RESULTS: Consecutive patients referred for CPVA from 2004 to 2009 underwent TEE within 48 h prior to the procedure. Of 408 patients included in the study, 6 patients (1.47%) had LA thrombi, persistent AF, and LA dilation. Compared with patients without thrombus, these six patients had larger LA diameter (P = 0.0001) and more frequently were women (P = 0.002), had persistent AF (P = 0.04), and had underlying structural cardiac disease (P = 0.014). The likelihood of presenting LA thrombus increased with the number of these four risk factors present (P < 0.001). None of the patients with paroxysmal AF and without LA dilation had LA thrombus. A cut-off value of 48.5 mm LA diameter yielded 83% sensitivity, 92% specificity, and a 10.1 likelihood ratio to predict LA thrombus appearance. CONCLUSION: The incidence of LA thrombus prior to CPVA is low. Persistent AF, female sex, structural cardiopathy, and LA dilation were associated with the presence of LA thrombus. Our data suggest that the use of TEE prior to CPVA to detect LA thrombi might not be needed in patients with paroxysmal AF and no LA dilation or structural cardiopathy.

Predictors of mortality and neurological function in ICU patients recovering from cardiac arrest: A Spanish nationwide prospective cohort study.

OBJECTIVE: To identify predictors of mortality and neurological function in adult ICU patients recovering from cardiac arrest. DESIGN: A prospective cohort multicenter study was carried out. SETTING: Forty-six polyvalent ICUs. PATIENTS: A total of 595 patients recovering from out-of-hospital cardiac arrest (OHCA, n=285) or in-hospital cardiac arrest (IHCA, n=310). MAIN OUTCOME VARIABLES: Survival and recovery of neurological function. RESULTS: The mean cardiopulmonary resuscitation time was 18min (range 10-30). Moderate hypothermia was used in 197 patients, and 150 underwent percutaneous coronary intervention (PCI). Return of spontaneous circulation (ROSC) was achieved within 20min in 370 patients. Variables associated to mortality (ICU and in-hospital) were age (odds ratio [OR]=1.0, 95%CI 1.0-1.0 per year), non-cardiac origin of cardiac arrest (OR=2.16, 95%CI 1.38-3.38; P=0.001) and ROSC >20min (OR=3.07, 95%CI 1.97-4.78; P<0.001), whereas PCI and the presence of shockable rhythm exhibited a protective effect. Favorable neurological outcome was associated to shockable rhythm, ROSC <20min, and cardiac origin of arrest. Hypothermia did not affect survival or neurological outcome in the multivariate analysis. CONCLUSIONS: Age, non-cardiac origin of cardiac arrest and ROSC >20min were predictors of mortality. In contrast, cardiac arrest of cardiac origin, ROSC <20min, and defibrillable rhythms were associated to unfavorable neurological outcomes.

ADENI-UCI Study: Analysis of non-income decisions in ICU as a measure of limitation of life support treatments. / Estudio ADENI-UCI: Análisis de las decisiones de no ingreso en UCI como medida de limitación de los tratamientos de soporte vital.

OBJECTIVE: To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure. DESIGN: Prospective, multicentrico SCOPE: 62 ICU from Spain between February 2018 and March 2019. PATIENTS: Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure. INTERVENTIONS: None. MAIN INTEREST VARIABLES: Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge. RESULTS: A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99). CONCLUSIONS: Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death.