Feasibility and effectiveness of opioid-free anesthesia in cytoreductive surgery with or without heated intraperitoneal chemotherapy.

BACKGROUND: Opioid-free anesthesia (OFA) provides analgesia minimizing opioids. OFA has not been evaluated in cytoreductive surgery (CRS) with or without heated intraperitoneal chemotherapy. We aim to evaluate OFA feasibility and effectiveness in CRS. METHODS: Retrospective cohort study of adult patients (84) undergoing CRS in a tertiary center from May 2020 until June 2021. Predefined protocols for either opioid-based anesthesia (OBA) or OFA were followed. RESULTS: OFA protocol patients (41) had better mean pain scores (1 ± 0.8 vs. 2 ± 1; p = 0.00) despite the avoidance of intravenous and epidural fentanyl intraoperatively (220 ± 104 and 194 ± 73 µg, respectively, in OBA vs. 0; p = 0.00). Postoperative epidural levobupivacaine was also lower in the OFA group (575 ± 192 vs. 706 ± 346 mg; p = 0.034) despite the lack of epidural fentanyl without difference in duration (4.3 ± 1.2 vs. 4 ± 1.2 days; p = 0.22). Morphine consumption was very low (4.1 ± 10 vs. 1.7 ± 5 mg; p = 0.16). Intraoperative hypertensive events and postoperative nausea and vomiting (PONV) were higher for OBA (43) (30.2% vs. 7.3%; p = 0.01% and 69.8% vs. 34.1%; p = 0.001, respectively). Postoperative epidural fentanyl was independently associated with PONV (p = 0.004). There was no difference in total complications or length of stay. CONCLUSION: OFA is feasible, safe, and offers optimal pain control while minimizing the use of opioids in CRS.

Percutaneous mitral valve repair with MitraClip device in hemodynamically unstable patients: A systematic review.

BACKGROUND: Very few data exist on percutaneous mitral valve repair (PMVr) in unstable patients with concomitant moderate-severe mitral regurgitation (MR). The purpose of this systematic review was to evaluate baseline characteristics, management and clinical outcomes of critically ill patients undergoing PMVr with MitraClip. METHODS: We conducted a systematic review of the published data on MitraClip from its first use in 2003 to December 2020. Studies referring to critically ill patients in cardiogenic shock or acute refractory pulmonary edema were included. A total of 40 publications including 254 patients with significant MR (Grade 4 in 91%) were included. RESULTS: Mean age was 70 ± 12 years with mean Euroscore II and STS of 21 ± 13 and 20.5 ± 16, respectively. Clinical presentation was with cardiogenic shock and acute myocardial infarction in 72.8 and 60.0% of patients, respectively. Device success was achieved in 238 (93.7%) patients with a significant reduction in MR (Grade ≤ 2 in 91.8%, p < .001). The median weaning time from the procedure, to discontinuation of mechanical circulatory or respiratory support, was 2 days (IQR 1-4), with an in-hospital mortality and non-fatal complication rate of 12.6 and 9.1%, respectively. Kaplan-Meier curves estimated an overall mortality rate of 39.1% at 12-month follow-up, with persistent reduction in MR severity for survivors (Grade ≤ 2 in 81.3%) and one case of mitral valve reintervention. CONCLUSIONS: Percutaneous mitral valve repair with MitraClip device is a technically feasible and potentially viable management option in high-risk patients with cardiogenic shock or refractory pulmonary edema and concomitant moderate-severe MR. Prospective trials are required to confirm these findings, and definitively determine the value of MitraClip in hemodynamically unstable patients.

Clinical picture, management and risk stratification in patients with cardiogenic shock: does gender matter?

BACKGROUND: Early recognition and risk stratification are crucial in cardiogenic shock (CS). A lower adherence to recommendations has been described in women with cardiovascular diseases. Little information exists about disparities in clinical picture, management and performance of risk stratification tools according to gender in patients with CS. METHODS: Data from the multicenter Red-Shock registry were used. All consecutive patients with CS were included. Both CardShock and IABP-SHOCK II risk scores were calculated. The primary end-point was in-hospital mortality. The discriminative ability of both scores according to gender was assessed by binary logistic regression, calculating Receiver operating characteristic (ROC) curves and the corresponding area under the curve (AUC). RESULTS: A total of 793 patients were included, of whom 222 (28%) were female. Women were significantly older and had a lower proportion of chronic obstructive pulmonary disease and prior myocardial infarction. CS was less often related to acute coronary syndromes (ACS) in women. The use of vasoactive drugs, renal replacement therapy, invasive ventilation, therapeutic hypothermia and mechanical circulatory support was similar between both groups. In-hospital mortality was 346/793 (43.6%). Mortality was not significantly different according to gender (p = 0.194). Cardshock risk score showed a good ability for predicting in-hospital mortality both in man (AUC 0.69) and women (AUC 0.735). Likewise, the IABP-II successfully predicted in-hospital mortality in both groups (man: AUC 0.693; women: AUC 0.722). CONCLUSIONS: No significant differences were observed regarding management and in-hospital mortality according to gender. Both the CardShock and IABP-II risk scores depicted a good ability for predicting mortality also in women with CS.

Late Migration of a Paravalvular Leak Closure Device.

Paravalvular leak (PVL) is a serious complication of surgical valve replacement, often affecting elderly, multimorbid, high-risk patients. The risk of surgical intervention is often prohibitive in these cases, and so percutaneous PVL closure emerged as a feasible and effective management strategy, with a low complication rate. Specific devices for closure of PVL's are currently not widely available, and so PVLs are closed using generic vascular closure devices, which may result in residual paravalvular regurgitation or even closure device displacement. Although rare, late displacement of the closure device with prosthetic impingement can be life threatening, requiring urgent intervention.We present a case of a seventy-year-old gentleman with rheumatic heart disease and multiple previous mechanical aortic and mitral valve replacements. After repeated admissions for decompensated heart failure, secondary to paravalvular mitral regurgitation, a percutaneous paravalvular leak closure was performed with successful reduction of the leak. He represented 30 days later with cardiogenic shock and multiorgan failure secondary to torrential central mitral regurgitation caused by late displacement of the closure device with mitral prosthesis impingement. Due to an excessively high surgical risk, his case was successfully managed percutaneously with retrieval of the displaced device and closure of the PVL using two Amplatzer Vascular Plug III devices. At the six-month review, he remains asymptomatic.Percutaneous PVL closure is an effective strategy for patients with prohibitive surgical risk. Late closure device displacement can be a life-threatening complication. Our case demonstrates that percutaneous management of this complication is feasible even in patients presenting in extremis.

Angiographic characteristics and long-term prognostic impact of coronary artery disease in survivors after sudden cardiac arrest with a non-diagnostic electrocardiogram.

OBJECTIVES: Our purpose was to describe the prevalence, distribution, extension, and prognostic value of coronary artery disease (CAD) in patients resuscitated from sudden cardiac arrest (SCA) with non-diagnostic electrocardiogram (ECG). BACKGROUND: The impact of CAD and the indication for cardiac catheterization (CC) in patients resuscitated from SCA with non-diagnostic ECG are uncertain. METHODS: We included prospectively and consecutively 545 patients resuscitated from SCA with at least one CC during hospitalization. From them, 203 patients with a non-diagnostic ECG formed our study population. Patients were followed-up 5 years after discharge. RESULTS: Overall, 125 (61.6%) patients had significant CAD, and at least one acute culprit lesion was found in 25 (12.4%). Regarding the burden and complexity of CAD, 78 (38.4%) patients had a CAD Prognostic Index of 0 and a SYNTAX score of 0. There was higher 5-year mortality only in patients with very high burden of CAD: three vessels with severe stenosis (P = 0.015) and CAD Prognostic Index Score ≥ 56 (P < 0.001). Tertiles of SYNTAX score did not predict higher 5-year mortality. CONCLUSIONS: In survivors from SCA with a non-diagnostic ECG, significant CAD is highly prevalent. SYNTAX score was not associated with a different long-term prognosis in this patient population. Patients with severe disease in the three main coronary vessels and patients with higher (≥56) CAD Prognostic Index Score had a worse long-term prognosis.

Clinical and hemodynamic results after direct transcatheter aortic valve replacement versus pre-implantation balloon aortic valvuloplasty: A case-matched analysis.

OBJECTIVES: To evaluate the safety and midterm hemodynamic results of direct transcatheter aortic valve replacement (TAVR) without pre-implantation balloon aortic valvuloplasty (BAV). BACKGROUND: BAV was considered a mandatory previous step in TAVR procedures. METHODS: A total of 339 consecutive patients who underwent transfemoral TAVR were prospectively selected. A 1:1 matching was conducted, pairing age, prosthesis type (self-expandable or balloon expandable) and size, and valve calcification grade (48% with moderate to severe valve calcification). Finally, 102 pairs (102 patients with previous BAV and 102 without BAV) were obtained. RESULTS: Direct TAVR was feasible in all patients without any crossover to BAV group. Device success was achieved in 91.2% and 90.2% of cases in direct TAVR and pre-BAV groups (P = 0.810), respectively, without any differences in balloon postdilation rate and residual aortic regurgitation. The amount of contrast agent, acute kidney injury and myocardial injury was significantly lower in the direct implantation group (P < 0.05). No differences were found in 30-day and 1-year mortality between both groups (4.9% vs. 9.8%, P = 0.177 and 14.0% vs. 23.8%, P = 0.771, respectively). Hemodynamic parameters remained stable after 1-year follow-up in both groups. CONCLUSIONS: Direct transfemoral TAVR without prior BAV was safe in patients with calcified severe aortic stenosis. Pre-implantation BAV could be omitted in patients undergoing TAVR, without influence in procedure success rate, and subsequent patients' clinical course and valve hemodynamic performance. © 2016 Wiley Periodicals, Inc.

Acute dilated cardiomyopathy in a patient with beriberi and cryoglobulinaemic vasculitis: an unusual potential complication of two rare disorders.

We report the case of a 45-year-old patient who presented with acute dilated cardiomyopathy. During admission the patient was consecutively diagnosed with cryoglobulinaemic vasculitis and beriberi. In both diseases, cardiac involvement may occur as dilated cardiomyopathy. Thiamin deficiency was the final cause for the severe cardiac manifestations (cardiac acute beriberi or Shoshin syndrome), which returned to normal after thiamin supplementation.

Predictors of major postoperative complications in cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy.

PURPOSE: Cytoreductive Surgery (CRS) ± Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is associated with a high incidence of postoperative morbidity. Our aim was to identify independent, potentially actionable perioperative predictors of major complications. METHODS: We reviewed patients who underwent CRS ± HIPEC from June 2020 to January 2022 at a high-volume center. Postoperative complications were categorized using the Comprehensive Complication Index, with the upper quartile defining major complications. Multivariate logistic analysis identified predictive and protective factors. RESULTS: Of 168 patients, 119 (70.8%) underwent HIPEC. Mean Comprehensive Complication Index was 12.6 (12.7) and upper quartile cut-off was 22.6. Medical complications were more frequent but less severe than surgical (63% vs 18%). Forty-six patients (27.4%) comprised the "major complications" group (mean CCI 30.1 vs 6.3). Multivariate logistic regression showed that heart disease (RR 1.9; 95% CI: 1.1 to 3.3), number of anastomoses (RR 2.4; 95% CI:1.3 to 4.6) and first 24-h fluid balance (RR 1.1; 95% CI: 1.1 to 1.2), were independently associated as risk factors for major complications, while opioid-free anesthesia (RR 0.6; 95% CI: 0.3 to 0.9) and high preoperative hemoglobin (RR 0.9; CI 95%: 0.9 to 0.9) were independent-protective factors. CONCLUSION: Preoperative heart diseases, number of anastomoses and first 24 h-fluid balance are independent risk factors for major postoperative complications, while high preoperative hemoglobin and opioid-free anesthesia are protective. Correction of anemia prior to surgery, avoiding positive fluid balance and incorporation of opioid-free anesthesia strategy are potential actionable measures to reduce postoperative morbidity.

Aortic Pseudoaneurysm-Related Acute Ortner's Syndrome Presenting as Sudden Hoarseness: A Case Series.

BACKGROUND Ortner syndrome, or cardiovocal syndrome, is a left recurrent laryngeal nerve palsy secondary to cardiovascular causes. Aortic pseudoaneurysm is a rare life-threatening condition resulting from weakening of the aortic wall. Clinical presentation of aortic pseudoaneurysm is highly variable. Hoarseness is often caused by benign conditions; however, it can be the first symptom of an underlying serious condition requiring immediate diagnosis and management. CASE REPORT We report a series of 2 patients with sudden hoarseness as the first symptom of an aortic arch pseudoaneurysm. Two men, with ages of 76 and 60 years, had sudden hoarseness a few weeks before. Laryngoscopy showed a left vocal cord palsy in both cases. A computed tomography (CT) scan showed a thoracic aortic pseudoaneurysm located at the aortic arch compressing the left recurrent laryngeal nerve. Both patients were treated with endovascular aortic repair. The first patient underwent a carotid-subclavian artery bypass, and the left subclavian artery was closed with a vascular plug device. He was discharged a week later, with persistent hoarseness. In the second case, subclavian artery occlusion and pseudoaneurysm embolization with coils were performed. Control CT scan confirmed the procedure's success. However, after an initial favorable evolution, the patient had severe non-vascular complications and finally died. CONCLUSIONS Considering these 2 cases and those reported in the literature, aortic origin should be considered in the differential diagnosis of hoarseness, particularly when it appears suddenly. Thoracic endovascular aortic repair is a feasible option for those patients with penetrating aortic ulcer or pseudoaneurysm located in the aortic arch.

Selective Extraction of Diazepam and Its Metabolites from Urine Samples by a Molecularly Imprinted Solid-Phase Extraction (MISPE) Method.

In this research, a molecularly imprinted polymer (MIP) was synthesized by precipitation polymerization using oxazepam (OZ) as a template molecule and was subsequently applied as a selective sorbent for the extraction of diazepam (DZP) and its metabolites in urine samples using an SPE cartridge. OZ, temazepam (TZ), nordiazepam (NZ) and DZP were analyzed in the final extracts by high-performance liquid chromatography with diode array detection (HPLC-DAD). The SPE extraction steps were optimized, and the evaluation of an imprinting factor was carried out. The selectivity of the method for OZ versus structurally related benzodiazepines (BZDs), such as bromazepam (BRZ), tetrazepam (TTZ) and halazepam (HZ), was investigated. Under the optimum conditions, the proposed methodology provided good linearity in the range of 10-1500 ng/mL, with limit of detection values between 13.5 and 21.1 ng/mL and recovery levels for DZP and its metabolites from 89.0 to 93.9% (RSD ≤ 8%) at a concentration level of 1000 ng/mL. The proposed method exhibited good selectivity, precision and accuracy and was applied to the analysis of urine samples from a real case of DZP intake.

Efficacy and safety of bempedoic acid in acute coronary syndrome. Design of the clinical trial ES-BempeDACS.

INTRODUCTION AND OBJECTIVES: Only about 1 out of every 3 patients with acute myocardial infarction (AMI) achieve low-density lipoprotein cholesterol (LDL-C) values <55mg/dL in the first year. The present study aims to evaluate the impact of early intensive therapy on lipid control after an AMI. METHODS: An independent, prospective, pragmatic, controlled, randomized, open-label, evaluator-blinded clinical trial (PROBE design) will analyze the efficacy and safety of an oral lipid-lowering triple therapy: high-potency statin+bempedoic acid (BA) 180mg+ezetimibe (EZ) 10mg versus current European-based guidelines (high-potency statin±EZ 10mg), in AMI patients. LDL-C will be determined within the first 48hours. Patients with LDL-C ≥ 115mg/dL (without previous statin therapy), ≥ 100mg/dL (with previous low-potency or high-potency statin therapy at submaximal dose), or ≥ 70mg/dL (with previous high-potency statin therapy at high dose) will be randomly assigned 1:1 between 24 and 72hours post-AMI to the BA/EZ combination or to statin±EZ, without BA. The primary endpoint is the proportion of patients reaching LDL-C <55mg/dL at 8 weeks after treatment. RESULTS: The results of this study will provide novel information for post-AMI LDL-C control by evaluating the usefulness of an early intensive lipid-lowering strategy based on triple oral therapy. CONCLUSIONS: Early intensive lipid-lowering triple oral therapy vs the treatment recommended by current clinical practice guidelines could facilitate the achievement of optimal LDL-C levels in the first 2 months after AMI (a high-risk period). IDENTIFICATION NUMBER: EudraCT 2021-006550-31.

Early versus delayed coronary angiography in patients with out-of-hospital cardiac arrest and no ST-segment elevation: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Recent randomized controlled trials did not show benefit of early/immediate coronary angiography (CAG) over a delayed/selective strategy in patients with out-of-hospital cardiac arrest (OHCA) and no ST-segment elevation. However, whether selected subgroups, specifically those with a high pretest probability of coronary artery disease may benefit from early CAG remains unclear. METHODS: We included all randomized controlled trials that compared a strategy of early/immediate versus delayed/selective CAG in OHCA patients and no ST elevation and had a follow-up of at least 30 days. The primary outcome of interest was all-cause death. Odds ratios (OR) were calculated and pooled across trials. Interaction testing was used to assess for heterogeneity of treatment effects. RESULTS: In total, 1512 patients (67 years, 26% female, 23% prior myocardial infarction) were included from 5 randomized controlled trials. Early/immediate versus delayed/selective CAG was not associated with a statistically significant difference in odds of death (OR 1.12, 95%-CI 0.91-1.38), with similar findings for the composite outcome of all-cause death or neurological deficit (OR 1.10, 95%-CI 0.89-1.36). There was no effect modification for death by age, presence of a shockable initial cardiac rhythm, history of coronary artery disease, presence of an ischemic event as the presumed cause of arrest, or time to return of spontaneous circulation (all P-interaction > 0.10). However, early/immediate CAG tended to be associated with higher odds of death in women (OR 1.52, 95%-CI 1.00-2.31, P = 0.050) than in men (OR 1.04, 95%-CI 0.82-1.33, P = 0.74; P-interaction 0.097). CONCLUSION: In OHCA patients without ST-segment elevation, a strategy of early/immediate versus delayed/selective CAG did not reduce all-cause mortality across major subgroups. However, women tended to have higher odds of death with early CAG.

Clinical profile, management and outcomes of patients with cardiogenic shock undergoing transfer between centers in Spain.

INTRODUCTION AND OBJECTIVES: The aim of this study was to analyze the clinical profile, management, and prognosis of ST segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) requiring interhospital transfer, as well as the prognostic impact of structural variables of the treating centers in this setting. METHODS: This study included patients with STEMI-CS treated at revascularization-capable centers from 2016 to 2020. The patients were divided into the following groups: group A: patients attended throughout their admission at hospitals with interventional cardiology without cardiac surgery; group B: patients treated at hospitals with interventional cardiology and cardiac surgery; and group C: patients transferred to centers with interventional cardiology and cardiac surgery. We analyzed the association between the volume of STEMI-CS cases treated, the availability of cardiac intensive care units (CICU), and heart transplant with hospital mortality. RESULTS: A total of 4189 episodes were included: 1389 (33.2%) from group A, 2627 from group B (62.7%), and 173 from group C (4.1%). Transferred patients were younger, had a higher cardiovascular risk, and more commonly underwent revascularization, mechanical circulatory support, and heart transplant during hospitalization (P<.001). The crude mortality rate was lower in transferred patients (46.2% vs 60.3% in group A and 54.4% in group B, (P<.001)). Lower mortality was associated with a higher volume of care and CICU availability (OR, 0.75, P=.009; and 0.80, P=.047). CONCLUSIONS: The proportion of transfers in patients with STEMI-CS in our setting is low. Transferred patients were younger and underwent more invasive procedures. Mortality was lower among patients transferred to centers with a higher volume of STEMI-CS cases and CICU.

New risk classification adapting SCAI shock stages to patients with pulmonary embolism (RISA-PE).

BACKGROUND: Pulmonary embolism (PE) treatment is based on risk stratification according to European Society of Cardiology (ESC) guidelines. However, emerging therapies in acute PE may require a more granular risk classification. Therefore, the objective of the present study was to propose a new RIsk claSsification Adapting the SCAI shock stages to right ventricular failure due to acute PE (RISA-PE). METHODS: This registry included consecutive intermediate-high risk (IHR) or high-risk (HR)-PE patients selected for catheter-directed interventions (CDI) from 2018 to 2023 in 15 Spanish centers (NCT06348459). Patients were grouped according to RISA-PE classification as A (right ventricular dysfunction and troponin elevation); B (A + serum lactate >2 mmol/L OR shock index ≥1); C (persistent hypotension); D (obstructive shock); and E (cardiac arrest). In-hospital adverse events were assessed to evaluate RISA-PE performance. RESULTS: A total of 334 patients were included (age 62.1±15.2 years, 55.7% males). The incidence of in-hospital all-cause death was progressively higher with increasing RISA-PE stage (1.2%, 6.4%, 19.0%, 25.6%, and 57.7% for stages A, B, C, D, and E, respectively, P value for linear trend<0.001). However, using the ESC classification, there was an abrupt difference between IHR- and HR-PE patients regarding mortality (4.3% vs. 29.3%, P<0.001). The incidence of in-hospital major bleeding and acute kidney injury followed a similar pattern. CONCLUSIONS: The user-friendly RISA-PE classification may improve the granularity in stratifying PE patients' risk and warrants evaluation in larger studies with different therapeutic approaches in order to detect its utility as a decision-making scale.

Hypothermia in comatose survivors from out-of-hospital cardiac arrest: pilot trial comparing 2 levels of target temperature.

BACKGROUND: It is recommended that comatose survivors of out-of-hospital cardiac arrest should be cooled to 32° to 34°C for 12 to 24 hours. However, the optimal level of cooling is unknown. The aim of this pilot study was to obtain initial data on the effect of different levels of hypothermia. We hypothesized that deeper temperatures will be associated with better survival and neurological outcome. METHODS AND RESULTS: Patients were eligible if they had a witnessed out-of-hospital cardiac arrest from March 2008 to August 2011. Target temperature was randomly assigned to 32°C or 34°C. Enrollment was stratified on the basis of the initial rhythm as shockable or asystole. The target temperature was maintained during 24 hours followed by 12 to 24 hours of controlled rewarming. The primary outcome was survival free from severe dependence (Barthel Index score ≥60 points) at 6 months. Thirty-six patients were enrolled in the trial (26 shockable rhythm, 10 asystole), with 18 assigned to 34°C and 18 to 32°C. Eight of 18 patients in the 32°C group (44.4%) met the primary end point compared with 2 of 18 in the 34°C group (11.1%) (log-rank P=0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients with initial shockable rhythm assigned to 32°C (61.5%) were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P=0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P=0.0002) in patients assigned to 32°C compared with 34°C. On the contrary, there was a trend toward a higher incidence of bradycardia (7 versus 2; P=0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups. CONCLUSIONS: The findings of this pilot trial suggest that a lower cooling level may be associated with a better outcome in patients surviving out-of-hospital cardiac arrest secondary to a shockable rhythm. The benefits observed here merit further investigation in a larger trial in out-of-hospital cardiac arrest patients with different presenting rhythms. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01155622.

[Factors associated with hospital admission and evaluation of a case management program for severe mental disorder by a historical cohort study]. / Factores asociados al ingreso hospitalario y evaluación de un programa de gestión de casos para trastorno mental grave mediante un estudio de cohortes históricas.

INTRODUCTION: People with severe mental disorder (SMD) have serious difficulties in developing a normal life, so community care programs to improve their living conditions and social integration are necessary. This work evaluates the performance of a case management program (CMP) in Segovia (Spain). METHODOLOGY: We conduct a first descriptive phase evaluating the performance of the CMP in 2011 by sociodemographic, health services and clinical variables. We study the factors associated with the occurrence of hospital admission. Finally, using a historical cohort design, we assess the risk of hospital admission of CMP compared to unexposed cohort. Bi and multivariate statistical techniques are employed to perform the analysis with the calculation of relative risks and confidence intervals. RESULTS: In 2011, 82 patients are cared for in the CMP, mainly middle-aged men. The average clinical course is 19 years and the average stay in the CMP over 6 years. 78% belong to the diagnosis of schizophrenia spectrum. Income affects 27% of patients. Women, mental health teams I-II, increased home visits and abandonment of monitoring are predictors of income, while the highest level of clinical course is protective. No protective effect of income is detected for the CMP in the different analyzes of the historical cohort study. CONCLUSIONS: It is necessary to systematically assess community care programs directed at SMD to make adjustments and modifications aiming at improving their clinical effectiveness.

Intravenous lidocaine infusion compared to thoracic epidural analgesia in cytoreductive surgery with or without heated intraperitoneal chemotherapy. A retrospective case-cohort study.

BACKGROUND: Intravenous (IV) lidocaine is a proven analgesic therapy but has not been evaluated in extensive procedures such as cytoreductive surgery (CRS). Our aim was to assess the effectiveness and safety of IV lidocaine in this setting. METHODS: This is a retrospective hybrid case-cohort study investigating analgesic effectiveness and complications of perioperative IV lidocaine at 1.5 mg/kg/h for 48 h compared to thoracic epidural anaesthesia (TEA) among patients undergoing CRS in a high-volume centre. RESULTS: Sixty patients were included, 20 received IV lidocaine and 40 underwent TEA. Pain scores were low (median ≤2) and similar in both groups (p = 0.88). At 72 h, the lidocaine group had a lower median pain score (p = 0.03). Overall opioid consumption in the first 48 h was lower in the lidocaine compared to the TEA group (median 0 (IQR 0-9.5) mg vs. 45.4 (0-62.4) MME respectively, p = 0.001). Opioid consumption was also lower in the lidocaine compared to the TEA group during the whole 5-day period (median 1 (IQR 1-13.5) mg vs. 112 (36.6-137.85) MME respectively, p = 0.000). The incidence of PONV was significantly lower in the lidocaine group (27.5% vs 5%, p = 0.047) with no difference in other complications or length of in-hospital stay. CONCLUSION: Intravenous lidocaine infusion may be a safe and effective analgesic approach in CRS and is associated with a significant reduction of opioid use and PONV compared to opioid-containing TEA.