Predictive factors of six-week mortality in critically ill patients with SARS-CoV-2: A multicenter prospective study.

OBJECTIVE: The objective of the study is to identify the risk factors associated with mortality at six weeks, especially by analyzing the role of antivirals and munomodulators. DESIGN: Prospective descriptive multicenter cohort study. SETTING: 26 Intensive care units (ICU) from Andalusian region in Spain. PATIENTS OR PARTICIPANTS: Consecutive critically ill patients with confirmed SARS-CoV-2 infection were included from March 8 to May 30. INTERVENTIONS: None. VARIABLES: Variables analyzed were demographic, severity scores and clinical condition. Support therapy, drug and mortality were analyzed. An univariate followed by multivariate Cox regression with propensity score analysis was applied. RESULTS: 495 patients were enrolled, but 73 of them were excluded for incomplete data. Thus, 422 patients were included in the final analysis. Median age was 63 years and 305 (72.3%) were men. ICU mortality: 144/422 34%; 14 days mortality: 81/422 (19.2%); 28 days mortality: 121/422 (28.7%); 6-week mortality 152/422 36.5%. By multivariable Cox proportional analysis, factors independently associated with 42-day mortality were age, APACHE II score, SOFA score at ICU admission >6, Lactate dehydrogenase at ICU admission >470U/L, Use of vasopressors, extrarenal depuration, %lymphocytes 72h post-ICU admission <6.5%, and thrombocytopenia whereas the use of lopinavir/ritonavir was a protective factor. CONCLUSION: Age, APACHE II, SOFA>value of 6 points, along with vasopressor requirements or renal replacement therapy have been identified as predictor factors of mortality at six weeks. Administration of corticosteroids showed no benefits in mortality, as did treatment with tocilizumab. Lopinavir/ritonavir administration is identified as a protective factor.

Predictive factors of six-week mortality in critically ill patients with SARS-CoV-2: A multicenter prospective study.

OBJECTIVE: The objective of the study is to identify the risk factors associated with mortality at six weeks, especially by analyzing the role of antivirals and munomodulators. DESIGN: Prospective descriptive multicenter cohort study. SETTING: 26 Intensive care units (ICU) from Andalusian region in Spain. PATIENTS OR PARTICIPANTS: Consecutive critically ill patients with confirmed SARS-CoV-2 infection were included from March 8 to May 30. INTERVENTIONS: None. VARIABLES: Variables analyzed were demographic, severity scores and clinical condition. Support therapy, drug and mortality were analyzed. An univariate followed by multivariate Cox regression with propensity score analysis was applied. RESULTS: 495 patients were enrolled, but 73 of them were excluded for incomplete data. Thus, 422 patients were included in the final analysis. Median age was 63 years and 305 (72.3%) were men. ICU mortality: 144/422 34%; 14 days mortality: 81/422 (19.2%); 28 days mortality: 121/422 (28.7%); 6-week mortality 152/422 36.5%. By multivariable Cox proportional analysis, factors independently associated with 42-day mortality were age, APACHE II score, SOFA score at ICU admission >6, Lactate dehydrogenase at ICU admission >470U/L, Use of vasopressors, extrarenal depuration, %lymphocytes 72h post-ICU admission <6.5%, and thrombocytopenia whereas the use of lopinavir/ritonavir was a protective factor. CONCLUSION: Age, APACHE II, SOFA>value of 6 points, along with vasopressor requirements or renal replacement therapy have been identified as predictor factors of mortality at six weeks. Administration of corticosteroids showed no benefits in mortality, as did treatment with tocilizumab. Lopinavir/ritonavir administration is identified as a protective factor.

Analysis of the smear layer generated by different activation systems: an in vitro study.

OBJECTIVES: To evaluate via scanning electron microscopy the amount of smear layer generated during the use of sonic and ultrasonic activation systems with standardized short-term intentional contacts with the canal walls. METHODOLOGY: Seventy single-root human teeth were randomly assigned to 2 control (n = 5 each): NC (negative control), PC (positive control) and four experimental groups (n = 15 each): NC (negative control), PC (positive control), G1 (passive ultrasonic irrigation with Irrisafe), G2 (ultrasonic irrigation with EndoUltra), G3 (sonic irrigation with Endoactivator), G4 (sonic irrigation with Eddy). Samples were instrumented with ProTaper Next®. An irrigation protocol with sodium hypochlorite (NaOCl) and ethylenediaminetetraacetic acid (EDTA) was followed for both PC and the experimental groups. Standardized intentional contacts were made in the mesial walls during 5 s at WL - 2 mm in all experimental groups. Two calibrated evaluators scored the smear layer generated with an ordinal scale by scanning electron microscopy. The weighted kappa coefficient (Kw) was calculated to determine the inter-observer agreement. Post-consensus ordinal data were analyzed using the ordinal (linear) chi-square test. RESULTS: When the agitation file is in contact with dentine walls, Irrisafe® significantly generated the least amount of smear layer in the coronal third (p < 0.05). Both in the middle and apical third, activation with Irrisafe® also showed statistically significant better results than Eddy™ and EndoUltra®. Endoactivator® showed significant better results than EndoUltra® and Eddy™ in the apical third (p < 0.05). CONCLUSIONS: Irrisafe generated the least amount of smear layer in the entire canal and similar to Endoactivator in the apical third when the agitation file is in contact with dentine walls. CLINICAL RELEVANCE: The smear layer is generated during activation. It is common to apply irrigation protocols where after the removal of the smear layer using chelants, a final rinse and activation is carried out but there are no previous studies analyzing the possible creation of a new smear layer with this final activation.

Tratamiento endobronquial de neumotórax persistente en síndrome de dificultad respiratoria aguda / Endobronchial treatment of persistent pneumothorax in acute respiratory distress syndrome

No disponible

Atmospheric degradation of 2-chloroethyl vinyl ether, allyl ether and allyl ethyl ether: Kinetics with OH radicals and UV photochemistry.

Unsaturated ethers are oxygenated volatile organic compounds (OVOCs) emitted by anthropogenic sources. Potential removal processes in the troposphere are initiated by hydroxyl (OH) radicals and photochemistry. In this work, we report for the first time the rate coefficients of the gas-phase reaction with OH radicals (kOH) of 2-chloroethyl vinyl ether (2ClEVE), allyl ether (AE), and allyl ethyl ether (AEE) as a function of temperature in the 263-358 K range, measured by the pulsed laser photolysis-laser induced fluorescence technique. No pressure dependence of kOH was observed in the 50-500 Torr range in He as bath gas, while a slightly negative T-dependence was observed. The temperature dependent expressions for the rate coefficients determined in this work are: The estimated atmospheric lifetimes (τOH) assuming kOH at 288 K were 3, 2, and 4 h for 2ClEVE, AE and AEE, respectively. The kinetic results are discussed in terms of the chemical structure of the unsaturated ethers by comparison with similar compounds. We also report ultraviolet (UV) and infrared (IR) absorption cross sections (σλ and σ(ν˜), respectively). We estimate the photolysis rate coefficients in the solar UV actinic region to be less than 10-7 s-1, implying that these compounds are not removed from the atmosphere by this process. In addition, from σ(ν˜) and τOH, the global warming potential of each unsaturated ether was calculated to be almost zero. A discussion on the atmospheric implications of the titled compounds is presented.

Cefalea... ¿y algo más?: Neuroimágenes en el estudio de la cefalea / Headache and something else? Neuroimaging in the study of headaches

Se revisa la iconografía de los hallazgos por tomografía computada (TC) y resonancia magnética (RM) de la cefalea, según nuestra experiencia. De acuerdo con la base MESH, esta entidad se define como un dolor craneano, que puede ser de ocurrencia benigna o la manifestación de una amplia gama de desórdenes. Las cefaleas se clasifican por su evolución temporal (aguda o crónica), presentación (en estallido, gravativa, etc.) o coexistencia de síntomas asociados, como auras, convulsiones o déficits focales. También se dividen en primarias o secundarias, según la existencia o no de una patología subyacente. Las primarias pueden tener manifestaciones clínicas definidas, pero en las secundarias ciertos signos y síntomas deben alertar sobre la presencia de una patología estructural. En este caso, las neuroimágenes tienen un rol esencial al detectar las causantes del cuadro. Nuestros hallazgos correspondieron a cefaleas primarias (p. ej: infarto migrañoso) y a etiologías orgánicas, entre las que se destacaron causas vasculares, como patología venosa (trombosis), vasoespasmo y leucoencefalopatía posterior reversible; hemorragias intraparen-quimatosas y extraaxiales; cefaleas postraumáticas y posquirúrgicas; y causas infecciosas y tumorales (apoplejía hipofisaria e hipertensión endocraneana). Además, hubo malformaciones (Arnold-Chiari, p.ej.) y otras como hipotensión endocraneana. En algunos casos inicialmente se realizó una TC y luego una RM, mientras que en otros la RM fue el método de elección. Las neuroimágenes facilitan el estudio de la cefalea, caracterizando la afección en primaria o secundaria. En el segundo caso permiten, a su vez, clasificar los hallazgos

A review is presented of the radiological findings (computed tomography -CT- and magnetic resonance imaging -MRI-) of headache, according to our experience. According to MESH database this entity is a skull based pain that can have a benign cause or be an expression of a wide spectrum of disorders. Headaches can be classified according to their temporal evolution (acute or chronic), presentation (blow up, aura, rapidly evolutionary, etc.), or according to associated symptoms, such as seizures or focal deficits. They could also be classified into primary or secondary, depending on the presence or absence of demonstrable disease. The primary headaches can have known symptoms (i.e. migraine), but in secondary ones certain symptoms and signs should alert on the existence of structural disease. At this point imaging methods have an outstanding role, as they allow detecting and identifying structural causes in patients with headache. Our findings corresponded to primary headaches (i.e.: migraine infarction) and organic aetiologies, such as vascular causes (venous thrombosis, vasospasm and posterior reversible leukoencephalopathy); intracerebral and extra-axial haemorrhage; post-surgical and post- traumatic headaches; and those due to infections and tumours (pituitary apoplexy or intracranial hypertension). Malformations, such as Arnold-Chiari's, and intracranial hypotension have also been found. In some cases a CT is initially performed and then an MR, whilst in others MR is the method of choice. Neuroimaging facilitates the study of headache, helping to characterise them into primary or secondary. In the latter case, the imaging also enables the findings to be classified

Application of the ambulatory care groups in the primary care of a European national health care system: does it work?

BACKGROUND: Ambulatory Care Groups (ACGs), a US case-mix system that uses the patient as the unit of analysis, is particularly appropriate for health care systems in which physicians serve a defined list of patients. OBJECTIVE: To determine the extent to which the categorization of patients according to ACGs would account for the utilization of primary care services in a national health care system within the European Union. METHODS: Of all subjects continuously assigned to 9 physicians from public primary health care centers in Bizkaia, Basque Country (Spain) over a 12-month period, those visited at least once (n = 9,093) were included. According to the subject's age, sex, and ICD-9-CM diagnoses assigned during a year of patient-provider encounters, patients were classified by means of the ACGs system. RESULTS: Multiple linear regression analyses indicated that age and sex did not explain more than 7.1% of the variance in annual visits made by adults and 25.7% by children to primary care physicians. However, the r2 adjusted to the ACGs model was 50% and 48%, respectively, and even higher, that is 58% and 64% for another component of the system, the Ambulatory Diagnostic Groups (ADGs). CONCLUSIONS: Those results support the inadequacy of using the patient's age and sex alone to estimate physicians' workload in the primary health setting and the need to consider morbidity categories. The ACGs case-mix system is a useful tool for incorporating patients' morbidity in the explanation of the use of primary health care services in a European national health system.

Understanding patient-initiated frequent attendance in primary care: a case-control study.

BACKGROUND: Frequent attendance, which accounts for a high proportion of the general practitioner's (GP's) workload, is still poorly understood. AIM: To assess the association and impact of exposure to chronic physical illness, mental disorders, life stress, and sociodemographic factors on the frequent attendance of primary health care medical services. METHOD: Nine general practices in Bizkaia, Spain, participated in a case-control study. Cases were patients who exceeded the 90th percentile in the distribution of the number of visits that they made on their own initiative from January 1993 to March 1994. Controls were those for whom a single, patient-initiated consultation was registered. A total of 102 cases and 100 controls were selected by stratified sampling proportional to the size of each practice. We estimated odds ratios and population attributable fractions for frequent attendance in relation to being exposed to the study variables, adjusted by demographic characteristics by means of logistic regression analysis. RESULTS: Medium-high life stress (adjusted odds ratio (AOR) = 4.5, 95% confidence interval (CI) = 1.7-12.8), chronic physical illness (AOR = 3.1; 95% CI = 1.4-6.9), mental disorder (AOR = 2.5; 95% CI = 1.3-5.1), and age were associated with patient-initiated frequent attendance. The adjusted population attributable fraction for chronic physical illness was 41%, 30.9% for mental disorder, and 15.2% for life stress. CONCLUSION: There is evidence that patient-initiated frequent attendance is related to genuine physical and psychosocial needs; therefore, recognition requires a bio-psychosocial approach on the part of GP.

Protection against sudden coronary occlusion by induced mild chronic volume hypertrophy in dogs.

A model of mild chronic volume hypertrophy in the dog has been described which consists of establishing a small arteriovenous (A-V) shunt. The model was utilized to evaluate the protection afforded by mild chronic volume hypertrophy against sudden coronary occlusion. Eight animals were studied, 4 with a single shunt (mean estimated 25% increase in cardiac output) and 4 with a double shunt (mean estimated 57% increase in cardiac output). The A-V shunt resulted in the expected volume hypertrophy by roentgenographic and cardiac weight criteria, but was small enough to produce no signs of exercise intolerance, cardiac failure, or definite electrocardiographic changes. After 6 months, the A-V fistulae were surgically closed and 2 weeks later, under normal hemodynamic conditions, the heart was challenged by sudden, permanent ligation of the left circumflex coronary artery at its origin. The time from ligation to death was measured and compared with 10 control animals without such fistulae. Death occurred in 2 to 13 min in the control animals; in contrast, 5 of the 8 animals with mild chronic volume hypertrophy survived longer than any control animal, and 2 were long-term survivors. The actuarial estimate of the difference in survival was significant (p=0.007) and indicated that the fistulae reduced the hazard of coronary ligation by a factor of 6. A single small shunt afforded protection similar to a double one. Therefore, mild chronic volume hypertrophy induced by a small A-V fistula in the normal dog protects against sudden coronary occlusion. We speculate that the procedure may have a role in the multifactorial prophylactic management of coronary artery disease in asymptomatic high risk subjects, instead of an inapplicable exercise program.

Replacement of the trachea with dura mater. Experimental work.

Results in a series of 30 dogs subjected to tracheal resection and repair are described. The dogs were divided into three groups. Seven to ten rings of the trachea were resected and then were replaced by a prosthesis made of dura mater and stainless steel wire. Different aspects of the procedures for respiratory support in the three groups are evaluated, as are the different kinds of prostheses used. Our results with ventilatory studies showed taht the mose effective means of respiratory support was insertion of an endotracheal tube after thoracotomy. Among the prostheses, the one used in the third group of dogs, a stainless steel spring covered with only one layer of dura mater, allowed a longer survival period but eventually caused late scarring and stenosis.

Influencia del Ph en el mecanismo de acción de las sustancias esclerosantes / Ph influence on the action mechanism of sclerosing substances

Se plantea que desde hace tiempo se conoce que la respuesta tisular, a la administración de sustancias esclerosantes del tipo de moruato de Na, siliato o tetrodecil sulfato de Na, todas irritantes tisulares, es inflamatoria aguda con el ulterior aumento de tejido fibroso denso. Se destaca que no obstante, en la literatura médica se ha reportado poco sobre el mecanismo de acción esclerosante de dichas sustancias. Es nuestro propósito tratar de esclarecer el papel que juega el Ph de las soluciones, como posible mecanismo de acción esclerosante. Se expresa que en la experiencia fueron utilizadas ratas adultas, a las cuales se les inyectaron diferentes soluciones con distintos Ph en patas traseras, sacrificándose en tiempo que osciló entre 24 horas y 30 días con el fin de obtener muestras para estudio histopatológico(AU)

Anestesia local producida por sustancias con acción estabilizante de la membrana / Local anesthesia produced by substances of membrane stabilizing action

Se demuestra la actividad anestésica local de antihistamínicos y un psicofarmaco. Se evidencia la presencia de reacción inflamatoria local pasajera con la cloraminopiridina, prometazina y dimenhidrinato, no así con la difenhidramina. Se constata que la potencia anestésica local de la imipramina (un psicofármaco) es superior a las restantes sustancias, inclusive la lidocaína, y que la incidencia de inflamaciones es menor. Se plantea que en caso de pacientes alérgicos a los anestésicos locales habituales, se pudieran utilizar en sustitución, los antihistamínicos y los psicofármacos para efectuar los procedimientos quirúrgicos habituales(AU)