[Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units]. / Recomendaciones para el manejo de los pacientes críticos con COVID-19 en las Unidades de Cuidados Intensivos.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

Recommendations for the management of critically ill patients with COVID-19 in Intensive Care Units.

The COVID-19 pandemic has led to the admission of a high number of patients to the ICU, generally due to severe respiratory failure. Since the appearance of the first cases of SARS-CoV-2 infection, at the end of 2019, in China, a huge number of treatment recommendations for this entity have been published, not always supported by sufficient scientific evidence or with methodological rigor necessary. Thanks to the efforts of different groups of researchers, we currently have the results of clinical trials, and other types of studies, of higher quality. We consider it necessary to create a document that includes recommendations that collect this evidence regarding the diagnosis and treatment of COVID-19, but also aspects that other guidelines have not considered and that we consider essential in the management of critical patients with COVID-19. For this, a drafting committee has been created, made up of members of the SEMICYUC Working Groups more directly related to different specific aspects of the management of these patients.

The use of ECMO in ICU. Recommendations of the Spanish Society of Critical Care Medicine and Coronary Units. / Empleo de ECMO en UCI. Recomendaciones de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias.

The use of extracorporeal membrane oxygenation systems has increased significantly in recent years; given this reality, the Spanish Society of Critical Intensive Care Medicine and Coronary Units (SEMICYUC) has decided to draw up a series of recommendations that serve as a framework for the use of this technique in intensive care units. The three most frequent areas of extracorporeal membrane oxygenation systems use in our setting are: as a cardiocirculatory support, as a respiratory support and for the maintenance of the abdominal organs in donors. The SEMICYUC appointed a series of experts belonging to the three working groups involved (Cardiological Intensive Care and CPR, Acute Respiratory Failure and Transplant work group) that, after reviewing the existing literature until March 2018, developed a series of recommendations. These recommendations were posted on the SEMICYUC website to receive suggestions from the intensivists and finally approved by the Scientific Committee of the Society. The recommendations, based on current knowledge, are about which patients may be candidates for the technique, when to start it and the necessary infrastructure conditions of the hospital centers or, the conditions for transfer to centers with experience. Although from a physiopathological point of view, there are clear arguments for the use of extracorporeal membrane oxygenation systems, the current scientific evidence is weak, so studies are needed that define more precisely which patients benefit most from the technique and when they should start.

"Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients. / Recomendaciones de "no hacer" en el tratamiento de los pacientes críticos de los grupos de trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. / Recomendaciones para el tratamiento de los pacientes críticos de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

Lumbalgia aguda con imagen «en suelta de globos» en la radiografía simple de tórax / Low back pain with a "detachable balloons" image in a simple chest X-ray

La imagen «en suelta de globos» en la radiografía simple de tórax no es muy común en atención primaria. Presentamos el caso de un paciente que consulta por lumbalgia no complicada. La radiografía de columna es indicativa de artrosis. Dentro del Programa de Actividades Preventivas PAPPS se le solicita análisis de sangre que muestra una anemia moderada. Durante el estudio posterior se descubre una imagen de nódulos pulmonares múltiples («en suelta de globos») en la radiografía simple de tórax. El paciente es remitido al hospital donde se detecta un probable carcinoma de células renales en la tomografía computarizada (TC) toracoabdominal. Finalmente, el síntoma inicial (lumbalgia) era debido a metástasis óseas pero se necesitó la posterior información para continuar con el proceso diagnóstico. La anemia y la imagen «en suelta de globos» fueron claves para el diagnóstico final (AU)

The "detachable balloons" image in simple chest-X-ray is not very common in Priamry Care. We present the case of patient who consulted for uncomplicated low back pain. The spine X-ray was suggestive of arthrosis. A blood analysis was requested within the Preventive Activities Programme, which showed moderate anaemia. The patient was referred to the Hospital where a probable renal cell carcinoma was detected in the thoraco-abdominal Computed Axial Tomography. Finally, the initial symptom (low back pain) was due to bone metastasis, but further information was required to continue with the diagnostic process. The anaemia and the "detachable balloons" image were key factors in the final diagnosis (AU)

[Low back pain with a "detachable balloons" image in a simple chest X-ray]. / Lumbalgia aguda con imagen «en suelta de globos¼ en la radiografía simple de tórax.

The "detachable balloons" image in simple chest-X-ray is not very common in Primary Care. We present the case of patient who consulted for uncomplicated low back pain. The spine X-ray was suggestive of arthrosis. A blood analysis was requested within the Preventive Activities Programme, which showed moderate anaemia. The patient was referred to the Hospital where a probable renal cell carcinoma was detected in the thoraco-abdominal Computed Axial Tomography. Finally, the initial symptom (low back pain) was due to bone metastasis, but further information was required to continue with the diagnostic process. The anaemia and the "detachable balloons" image were key factors in the final diagnosis.

[Early invasive strategy in non-ST-segment elevation acute coronary syndrome. The paradox continues]. / Uso de la estrategia invasiva precoz en el síndrome coronario agudo sin elevación de ST. La paradoja continúa.

OBJECTIVE: Observational studies have reported a paradoxical inverse relationship between the use of an early invasive strategy (EIS) and the risk of events in patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS). The study objectives are: 1) to examine the association between baseline risk in patients with NSTE ACS and the use of EIS; and 2) to identify some of the factors independently associated to the use of EIS. DESIGN: Retrospective cohort study. SETTING: Intensive care units participating in the SEMICYUC ARIAM Registry. PATIENTS: Consecutive patients admitted with a diagnosis of NSTE-ACS within 48 hours of evolution between the months of April-July 2010. INTERVENTIONS: None. MAIN OUTCOMES: Coronary angiography with or without angioplasty within 72 hours, risk stratification using the GRACE scale. RESULTS: We analyzed 543 patients with NSTE-ACS, of which 194 were of low risk, 170 intermediate risk and 179 high risk. The EIS was used in 62.4% of the patients at low risk, in 60.2% of those with intermediate risk, and in 49.7% of those at high risk (p for tendency 0.0144). The EIS was used preferentially in patients with low severity and comorbidity. In the logistic regression model, EIS was independently associated to the availability of a catheterization laboratory (OR 2.22 [CI 95% 1.55 to 3.19]), the presence of ST changes on ECG (OR 1.80 [1.23 to 2.64]), or the existence of a low risk of bleeding (OR 0.76 [0.66 to 0.88)]. Conversely, EIS was less prevalent in patients with diabetes (OR 0.60 [0.41 to 0.88]) or tachycardia upon admission (OR 0.54 [0 36 to 0.82]). CONCLUSIONS: In 2010 there remained a lesser relative use of EIS in patients at high risk, due in part to an increased risk of bleeding in these patients.

[Quality indicators in the acute coronary syndrome for the analysis of the pre- and in-hospital care process]. / Indicadores de calidad en el síndrome coronario agudo para el análisis del proceso asistencial pre e intrahospitalario.

We present a map of 27 indicators to measure the care quality given to patients with acute coronary syndrome attended in the pre- and hospital area. This includes technical process indicators (registration of care intervals, performance of electrocardiogram, monitoring and vein access, assessment of prognostic risk, hemorrhage and in-hospital mortality, use of reperfusion techniques and performance of echocardiograph), pharmacological process indicators (platelet receptors inhibition, anticoagulation, thrombolysis, beta-blockers, angiotensin converting inhibitors and lipid lowering drugs) and outcomes indicators (quality scales of the care given and mortality).

N-glycans harboring the Lewis a epitope are expressed at the surface of plant cells.

In plants, N-linked glycans are processed in the Golgi apparatus to complex-type N-glycans of limited size containing a beta(1,2)-xylose and/or an alpha(1,3)-fucose residue. Larger mono- and bi-antennary N-linked complex glycans have not often been described. This study has re-examined the structure of such plant N-linked glycans, and, through both immunological and structural data, it is shown that the antennae are composed of Lewis a (Le(a)) antigens, comprising the carbohydrate sequence Gal beta 1-3[Fuc alpha 1-4]GlcNAc. Furthermore, a fucosyltransferase activity involved in the biosynthesis of this antigen was detected in sycamore cells. This is the first characterization in plants of a Lewis antigen that is usually found on cell-surface glycoconjugates in mammals and involved in recognition and adhesion processes. Le(a)-containing N-linked glycans are widely distributed in plants and highly expressed at the cell surface, which may suggest a putative function in cell/cell communication.

Simple and sensitive determination of urea in serum and urine.

In this method for serum and urinary urea determination, the same reagent is used without predilution of urine samples. The method is based on the pH increase resulting from the ammonia released by urease hydrolysis of urea. o-Cresolphthalein complexone is used to monitor the pH change colorimetrically. Urea concentration and absorbance at 570 nm are linearly related for concentrations as great as 600 mmol/L for urine samples and 100 mmol/L for serum. There are no clinically significant interferences from physiological substances or drugs, and precision and accuracy are excellent (CV approximately 2%, except at very low concentrations in serum; analytical recovery was 99% in urine, 100% in serum). Results by this method (y) and by the Astra method (x) for urine correlated well (y = 0.991x - 2.87, Sy/x = 9.21, r = 0.994), as did the results by this method and by the total enzymatic method (x') for serum (y = 1.002x' + 0.192, Sy/x' = 0.598, r = 0.997). This method is applicable to automated as well as manual instruments, and one-reagent or two-reagent formats can be used.

[Contrast echocardiography in the diagnosis of severe hypoxemia associated with liver cirrhosis]. / Ecocardiografía de contraste en el diagnóstico de la hipoxemia grave asociada a cirrosis hepática.

Severe hypoxemia is an uncommon feature of hepatic cirrhosis. Its major cause are intrapulmonary arteriovenous shunts, both due to direct arteriovenous communications and abnormally dilated pulmonary capillaries. In the present study, a case of cirrhosis associated with severe hypoxemia is reported. Contrast echocardiography showed pulmonary arteriovenous shunts, and low values of mixed venous blood (15% or less were obtained with the method of 100% oxygen breathing). These data suggest that the basic mechanism of hypoxemia, in this case, were capillary dilatations rather than true pulmonary arteriovenous anastomoses. The pathophysiological mechanisms of hypoxemia in cirrhosis are discussed, with emphasis on the present relevance of echocardiography for a full evaluation of these patients, particularly when liver transplantation is contemplated.

[Esophageal tuberculosis and massive hematemesis]. / Tuberculosis esofágica y hematemesis masiva.

A patient with esophageal tuberculosis who died of massive hematemesis is described. The origin of the disease was probably pulmonary and the esophageal affliction could have been produced by both the ingestion of contaminated sputum or direct extension from mediastinal lymphatic nodes. The diagnosis was reached by the discovery of caseation granulomas at esophagoscopy and the isolation of Mycobacterium Tuberculosis in the sputum. We comment on the rareness of the disease, clinical and endoscopic features which can resemble a neoplasia. At the same time, we highlight the possibility of serious complications, mainly upper gastrointestinal hemorrhage which is potentially lethal, and the aorto-esophageal communication, thus early diagnosis and surgical treatment being most important.