5-year mortality in cardiac surgery patients with low cardiac output syndrome treated with levosimendan: prognostic evaluation of nt-probnp and c-reactive protein.

AIM: To determine the clinical risk factors predictive of the 5--year mortality in patients with low cardiac output syndrome (LCOS) after cardiac surgery. In addition, to assess the influence of inflammation and myocardial dysfunction severity, as measured by C--reactive protein (CRP) and N--terminal pro--brain natriuretic peptide (NT--proBNP) concentrations, on outcome. METHODS: We studied 30 patients who underwent cardiac surgery and developed postoperative LCOS requiring inotropic support for longer than 48 hours after intensive care unit (ICU) admission. All patients received a 24--hour infusion of levosimendan after study enrolment. We measured the following at baseline, 24 h, 48 h and 7 days: clinical data, serum NT--proBNP and serum CRP levels. Patients were followed--up at 5 years for death by any cause. A risk--adjusted Cox proportional hazards regression model was used for statistical analysis. Hazard ratios and their 95% confidence intervals (CI) are presented. RESULTS: The 5--year mortality was 36.6% (n = 11). The predictors of 5--year mortality were the presence of dilated cardiomyopathy (HR = 36.909; 95% CI: 1.901-716.747; P = 0.017), a higher central venous pressure (CVP) at 48 hours (HR = 2.686; 95% CI: 1.383-5.214; P = 0.004), and lower CRP levels on day 7 (HR = 0.963; 95% CI: 0.933-0.994; P = 0.021). NT--proBNP levels showed a trend to higher initial levels in survivors without statistical significance, but were not associated with 5--year mortality. CONCLUSIONS: The presence of dilated cardiomyopathy, elevated CVP at 48 h and reduced CRP levels on day 7 predicted 5--year mortality in patients who developed postoperative LCOS after cardiac surgery. NT--proBNP levels in the first postoperative week were not predictors of long--term outcomes.

Predictors of long-term mortality in patients with cirrhosis undergoing cardiac surgery.

AIM: Little is known regarding the long-term outcome in cirrhotic patients undergoing cardiac surgery. The objective of this study was to identify preoperative and postoperative mortality risk factors and to determine the best predictors of long-term outcome. METHODS: Fifty-eight consecutive cirrhotic patients requiring cardiac surgery between January 2004 and January 2009 were prospectively studied at our institution. Seven patients (12%) died. A complete follow-up was performed in the whole survival group until November 2012 (mean 46±28 months). Variables usually measured on admission and during the first 24 h of the postoperative period were evaluated together with cardiac surgery scores (Parsonnet, EuroSCORE), liver scores (Child-Turcotte-Pugh, Model for End-Stage Liver Disease, United Kingdom End-Stage Liver Disease score), and ICU scores (Acute Physiology and Chronic Health Evaluation II and III, Simplified Acute Physiology Score II and III, Sequential Organ Failure Assessment). RESULTS: Twelve patients (23.5%) died during follow-up; six were Child class A and six class B. Comparing survivors vs. non-survivors using univariate analysis, variables associated with better long-term outcome were lower arterial lactate 24 h after admission (1.7±0.4 vs. 2.1±0.7 mmol·L(-1), P=0.03) and higher urine output in the first 24 h (2029±512 vs. 1575±627 mL, P=0.03). The receiver operating characteristic curve showed that the Simplified Acute Physiology Score III score had the best predictive value for long-term outcome (AUC: 77.4±0.76%; sensitivity: 83.3%; specificity: 64.9%, P=0.005). Multivariate analysis identified Simplified Acute Physiology Score III score (P=0.02) and urine output in the first 24 h (P=0.02) as independent factors associated with long-term outcome. Long-term survival was 82.4% for Child A, 47.6% for Child B and 33.3% for Child C (P=0.001). CONCLUSION: Long-term survival in cirrhotic patients requiring cardiac surgery is a more valuable prognostic measure than short-term survival. Urine output in the first 24 h may be a valuable predictor of long-term outcome in these patients. The Simplified Acute Physiology Score III is also useful.

Place of death in patients with amyotrophic lateral sclerosis.

UNLABELLED: Amyotrophic lateral sclerosis (ALS) is a degenerative neurological disorder that affects motor neurons. Involvement of respiratory muscles causes the failure of the ventilator pump with more or less significant bulbar troubles. ALS course is highly variable but, in most cases, this disease entails a very significant burden for patients and caregivers, especially in the end-of-life period. In order to analyze the characteristics of ALS patients who die at home (DH) and in hospital (DHosp) and to study the variability of clinical practice, a retrospective medical records analysis was performed (n=77 from five hospitals). VARIABLES: time elapsed since the onset of symptoms and the beginning of ventilation, characteristics of ventilation (device, mask and hours/day), and support devices and procedures. RESULTS: In all, 14% of patients were ventilated by tracheotomy. From the analysis, 57% of patients were of DH. Mean time since the onset of symptoms was 35.93±25.89 months, significantly shorter in patients who DHosp (29.28±19.69 months) than DH (41.12±29.04) (p=0.044). The percentage of patients with facial ventilation is higher in DHosp (11.4% vs 39.4%, p<0.005). DH or not is related to a set of elements in which health resources, physician attitudes and support resources in the community play a role in the decision-making process. There is great variability between countries and between hospitals in the same country. Given the variability of circumstances in each territory, the place of death in ALS might not be the most important element; more important are the conditions under which the process unfolds.

Is short-term amiodarone use post cardiac surgery a cause of acute respiratory failure?

AIM: It was believed that amiodarone-related adverse respiratory effects were found only when receiving amiodarone on a long-term basis, but several reports seem to contradict this hypothesis. The aim of this study was to evaluate, in an intensive care unit (ICU), the possibility of acute respiratory toxicity induced by short-term amiodarone administration following cardiac surgery. METHODS: We conducted a prospective clinical trial of 111 consecutive patients admitted to our ICU after cardiac surgery (basically, coronary artery bypass graft and/or valve surgery) and who received short-term prophylactic amiodarone treatment if they were considered at high risk of developing atrial fibrillation. We administered 900 mg/day intravenously for the first 2 days and 600 mg/day on the following days of the ICU stay. The oxygenation index (PaO2/FiO2 ratio) was evaluated at admission, and then 24 and 48 h postsurgery. RESULTS: One-hundred and two patients were included in the study (9 were excluded for bradycardia), and 25 received amiodarone treatment. The Parsonnet and APACHE II scores differed slightly between the treated and nontreated groups. There were no significant differences between the treated and nontreated groups with respect to left atrial pressure, the number of packed red cells transfused or the oxygenation index at admission and 24 and 48 h postsurgery. CONCLUSION: The short-term administration of amiodarone under the conditions of the present study does not seem to affect respiratory function.

Noninvasive positive pressure ventilation prevents postoperative pulmonary complications in chronic ventilators users.

OBJECTIVE: To evaluate the postoperative pulmonary complications and the long-term impact on pulmonary function of different surgical procedures with general anaesthesia in chronic respiratory failure (CRF) patients who were using noninvasive positive pressure ventilation (NPPV). DESIGN: We retrospectively studied 20 stable patients on NPPV for CRF secondary to: kyphoscoliosis (eight), morbid obesity (six), thoracoplasty (four), neuromuscular diseases (two), who underwent surgical procedures with general anaesthesia, between January 1998 and December 2003. MATERIAL AND METHODS: The variables studied were: type of surgery, hours of orotracheal intubation, hours of stay in the postsurgical reanimation unit (PRU), postoperative pulmonary complications and days of hospital stay. These results were compared with those obtained in patients without respiratory pathology and who were submitted to the same type of surgical interventions during the study period. All patients were tested for: arterial blood gases, forced vital capacity (FVC) and forced expiratory volume in 1s (FVE1). These tests were carried out both prior to surgical intervention and 12 months after this intervention, and the use of medical assistance resources the year prior to and the year after the surgical intervention were also analysed. RESULTS: Sixteen patients were using NPPV at home at the time of the intervention and four patients were adapted to NPPV before surgery. The surgical procedures were: gastroplasty: six; mastectomy: five; septoplasty: three; hip prosthesis: two; cholecystectomy: one; Gasserian ganglion thermocoagulation: one; hysterectomy: one; and endoscopic retrograde cholangiopancreatography (ERCP): one. The mean postoperative intubation time was 3.8+/-3.2h, and only one patient remained intubated for more than 12h. The mean stay in the PRU was 19+/-9h (vs 19+/-6h in the general population, p>0.05). The days of hospital stay for the different pathologies were in the majority of cases greater than in the general population. We did not find significant differences on comparing the arterial blood gases, in pulmonary function or in use of assistance resources between the year previous to and the year following the surgical intervention. CONCLUSIONS: In high-risk patients with chronic respiratory failure as a consequence of a restrictive lung pathology, NPPV can play an important role to confront surgical procedure with general anaesthesia with greater security. To obtain these results, it was fundamental to coordinate between the Pulmonary Services and the Anaesthesia Services as well as to follow up jointly in the PRU.

Selective prophylaxis of atrial fibrillation with amiodarone after cardiac surgery.

AIM: Atrial fibrillation (AF) is common after cardiac surgery, but prophylaxis for patients especially prone to developing this arrhythmia has not been studied to date. We investigated amiodarone as prophylaxis for AF in selected patients after open-heart surgery. METHODS: In the first stage we studied a group of 204 consecutive cardiac surgery patients and devised a formula from some of the known risk factors of AF for each sex to serve as a predictor model. In this first group we were able to quantify the probability of developing this arrhythmia. In the second stage we applied this formula to a group of 231 consecutive cardiac surgery patients and then selectively treated the high-risk patients for AF: 25 men (16.1%) and 29 women (53.7%). In the first 24 h of treatment with amiodarone, 22 patients (10 men and 12 women) were excluded from the study due to sinus bradycardia. Therapy consisted of amiodarone 900 mg intravenously every 24 h for the first 2 postoperative days, followed by 600 mg intravenously every 24 h until discharge from the Intensive Care Unit. RESULTS: Expected AF in males fell from 34.4% (52/151) in the observation group to 11% (17/155) in the treated group, and in females from 50.9% in the observation group (27/53) to 9.3% (5/54) in the treated group (P<0.001). CONCLUSIONS: Patient-selective prophylaxis of AF with amiodarone can be a highly effective measure.

Bacterial infection in exacerbated COPD with changes in sputum characteristics.

We examined the risk factors for bacterial exacerbation, defined as the presence of pathogenic bacteria in sputum, in 90 chronic obstructive pulmonary disease (COPD) patients with an exacerbation and changes in sputum characteristics. Smoking, alcohol, lung function, body mass index, medical visits and treatments were the independent variables assessed using multivariable logistic regression modelling (OR, 95% CI). A bacterial exacerbation was diagnosed in 39 (43.3%) of 90 patients. Bacterial exacerbations were more prevalent among current smokers (OR 3.77, 95% CI 1.17-12.12), in patients with poor compliance with inhalation therapy (OR 3.25, 95% CI 1.18-8.93) and with severe lung function impairment (FEV1 OR 0.96, 95% CI 0.93-1.00). Prior use of antibiotics was a risk factor for Pseudomonas aeruginosa infection (OR 6.06, 95% CI 1.29-28.44) and influenza vaccination appeared to have a protective effect against this infection (OR 0.15, 95% CI 0.03-0.67). We conclude that severe impairment of lung function, smoking and poor compliance with therapy are risk factors for bacterial infection in COPD, and P. aeruginosa should be suspected in patients who have been treated with antibiotics and in those not vaccinated against influenza.

Toma de decisiones en el manejo clínico de los pacientescon esclerosis lateral amiotrófica / Decision making in the clinical management of patients with lateral amyotrophic sclerosis

No disponible

Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients.

It was postulated that home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) exacerbations admitted at the emergency room (ER) could facilitate a better outcome than conventional hospitalisation. To this end, 222 COPD patients (3.2% female; 71+/-10 yrs (mean+/-SD)) were randomly assigned to HH (n=121) or conventional care (n=101). During HH, integrated care was delivered by a specialised nurse with the patient's free-phone access to the nurse ensured for an 8-week follow-up period. Mortality (HH: 4.1%; controls: 6.9%) and hospital readmissions (HH: 0.24+/-0.57 controls: 0.38+/-0.70) were similar in both groups. However, at the end of the follow-up period, HH patients showed: 1) a lower rate of ER visits (0.13+/-0.43 versus 0.31+/-0.62); and 2) a noticeable improvement of quality of life (delta St George's Respiratory Questionnaire (SGRQ), -6.9 versus -2.4). Furthermore, a higher percentage of patients had a better knowledge of the disease (58% versus 27%), a better self-management of their condition (81% versus 48%), and the patient's satisfaction was greater. The average overall direct cost per HH patient was 62% of the costs of conventional care, essentially due to fewer days of inpatient hospitalisation (1.7+/-2.3 versus 4.2+/-4.1 days). A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective. The home hospitalisation intervention generates better outcomes at lower costs than conventional care.

Risk factors of readmission to hospital for a COPD exacerbation: a prospective study.

BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) are a leading cause of admission to hospital among men in many countries, although the factors causing exacerbations are largely unknown. The association between readmission for a COPD exacerbation and a wide range of modifiable potential risk factors, after adjusting for sociodemographic and clinical factors, has been assessed. METHODS: Three hundred and forty patients with COPD recruited during an admission for an exacerbation in four tertiary hospitals in the Barcelona area of Spain were followed for a mean period of 1.1 years. Information on potential risk factors, including clinical and functional status, medical care and prescriptions, medication adherence, lifestyle, health status, and social support, was collected at the recruitment admission. A Cox's proportional hazards model was used to obtain independent relative risks of readmission for COPD. RESULTS: During the follow up period 63% of patients were readmitted at least once, and 29% died. The final multivariate model showed the following risk (or protective) factors: > or =3 admissions for COPD in the year before recruitment (hazard ratio (HR)=1.66, 95% CI 1.16 to 2.39), forced expiratory volume in 1 second (FEV(1)) percentage predicted (0.97, 95% CI 0.96 to 0.99), oxygen tension (0.88, 95% CI 0.79 to 0.98), higher levels of usual physical activity (0.54, 95% CI 0.34 to 0.86), and taking anticholinergic drugs (1.81, 95% 1.11 to 2.94). Exposure to passive smoking was also related to an increased risk of readmission with COPD after adjustment for clinical factors (1.63, 95% CI 1.04 to 2.57) but did not remain in the final model. CONCLUSIONS: This is the first study to show a strong association between usual physical activity and reduced risk of readmission to hospital with COPD, which is potentially relevant for rehabilitation and other therapeutic strategies.

Impact of a hospital-based home-care program on the management of COPD patients receiving long-term oxygen therapy.

STUDY OBJECTIVES: To analyze the influence of a hospital-based home-care program (HCP) on the management of patients with COPD receiving long-term oxygen therapy. DESIGN AND SETTING: Randomized, controlled study in a 1,000-bed university hospital. INTERVENTION: The HCP applied to patients in the intervention group (HCP group) consisted of a monthly telephone call, home visits every 3 months, and home or hospital visits on a demand basis. Patients in the control group were given conventional medical care. MEASUREMENTS: Pulmonary function data, gas exchange, use of hospital resources (emergency department visits, admissions, and hospital stay) and the cost of medical assistance were investigated in both groups before and after 1 year of study. Quality of life was analyzed using the chronic respiratory questionnaire in the first 40 consecutive patients included in the study. Survival throughout the study was also assessed. RESULTS: One hundred twenty-two patients were enrolled in the study, and 94 patients (46 in the HCP group and 48 in the control group) completed the 1-year follow-up period: 83 patients (88%) were men, and mean (+/- SD) age was 68 +/- 8 years. During the follow-up period, there was a highly significant decrease in the mean number of emergency department visits (0.45 +/- 0.83 vs 1.58 +/- 1.96; p = 0.0001) and also a significant decrease in hospital admissions (0.5 +/- 0.86 vs 1.29 +/- 1.7; p = 0.001) and days of hospital stay (7.43 +/- 15.6 vs 18.2 +/- 24.5; p = 0.01) in the HCP group. Patients in the intervention group required a total of 221 home visits (mean per patient, 4.8 +/- 0.8) and 69 hospital visits (mean per patient, 1.5 +/- 1.07). In spite of the cost of the program, cost analysis showed a total saving of 8.1 million pesetas ($46,823) in the HCP group, mainly due to a decrease in the use of hospital resources. There was no difference in pulmonary function, gas exchange, quality of life, and survival between the two groups. CONCLUSIONS: Hospital-based home care is an effective alternative to hospital admission. It reduces the use of hospital resources and the cost of health care.

Sexuality in chronic respiratory failure: coincidences and divergences between patient and primary caregiver.

Sexual functioning can be affected by chronic illness in a variety of ways. These problems affect the patients relationship and the degree of satisfaction with his partner. We conducted a study in order to evaluate the perception of sexual difficulties and changes in communication with patients and their wives. Male chronic obstructive pulmonary disease patients with (COPD) and chronic respiratory failure on long-term oxygen therapy were studied. The evaluation method used has consisted of the individualized administration of a semi-structured interview created for this purpose. This interview was conducted with the patients and their wives. One part of the interview was dedicated to evaluating possible sexual problems and how these problems affect the relationship between the couples. In addition, patients as well as their partners were asked the degree of satisfaction with their partners and the degree of satisfaction with their lives. Forty-nine patients and their spouses have been included in the study. Thirty-three patients (67.3%) showed some type of sexual problem (lack of desire and/or impotence). Sixteen wives (33%) answered affirmatively to the question about whether changes at a communicative level as a consequence of the patients illness had occurred. In relation to the appearance of sexual changes, 46 (94%) of the wives answered affirmatively. The wives were significantly less satisfied with the relationship than the patients, which was related to communication problems. The group of patients were more satisfied with their partners than with their life, whereas no difference has been observed in the wives with both variables. An important percentage of patients with chronic insufficiency who have sexual difficulties exits. A factor which influences the perception of such problems in a very important way is the degree of affection in the relationship between the couples.

Using the EuroQol-5D to measure changes in quality of life 12 months after discharge from an intensive care unit.

OBJECTIVE: To compare changes in the health-related quality of life (HRQOL) of critical care patients by diagnostic category. DESIGN: Prospective, cohort study. HRQOL assessed 3 months before admission and 1 year after discharge from the intensive care unit (ICU). Patients were classified as: trauma injury (TI), scheduled surgery (SS), unscheduled surgery (US), and other medical conditions (MC). SETTING: Department of Intensive Medicine, University Hospital of Bellvitge, Barcelona, Spain. PATIENTS: Three hundred and thirty-four patients admitted to ICU from October 1994 to June 1995 (62 TI patients, 181 SS patients, 19 US patients, and 72 MC patients). INTERVENTIONS: Surgical and medical procedures. MEASUREMENTS AND RESULTS: Changes in HRQOL varied considerably between diagnostic categories, with TI patients having significantly worse HRQOL one year after discharge from the ICU compared to 3 months prior to admission [change in median EQ Visual Analogue Scale (EQ-VAS) score from 100 to 65, P<0.001], and SS patients reporting improved HRQOL (change in median EQ-VAS scores from 60 to 75, P<0.001). Slight deterioration was observed in the other two diagnostic categories. Twelve months after discharge, the EQ dimension in which the largest proportion of patients in all groups reported problems was usual activities (47% of SS and US patients; 69% of TI patients). Using proxy scores at baseline or follow-up had little effect on results. CONCLUSIONS: The degree and direction of change in ICU patients' HRQOL 1 year after discharge depends considerably on diagnostic category. Proxy responses can be reliably used with the EQ-5D when measuring change in HRQOL.

Patients hospitalized for COPD have a high prevalence of modifiable risk factors for exacerbation (EFRAM study).

There is little information available concerning the extent to which chronic obstructive pulmonarv disease (COPD) patients are satisfactorily managed, especially, regards factors supposedly related to COPD exacerbation. The present study assessed the prevalence rates of potentially modifiable risk factors of COPD exacerbation in patients hospitalized for this reason. A systematic sample of one out of two patients admitted for COPD exacerbation, during 1 yr, in four tertiary hospitals in the Barcelona area, Spain, was performed. Patients answered a questionnaire and underwent anthropometric measurements, spirometric tests and arterial blood gas sampling. Prevalence rates and 95% confidence intervals (95% CI) for risk factors were obtained, and the generalized estimating equation (GEE) method was used to allow for patients to provide information on different admissions. The study recruited 353 patients (29 female) with a total of 404 admissions age (mean+/-SD) 69+/-9, median forced expiratory volume in one second (FEV1) 31% of predicted and mean partial pressure of oxygen (PO2) 63+/-13 mmHg. Of these, 28% had not received an influenza vaccination; a high number (86%) did not attend rehabilitation programmes; 28% of patients with PO2 < or =55 mmHg were not using long-term oxygen therapy (LTOT); among LTOT users, 18% used it <15 h a day; 43% of the total failed in some of the essential inhaler manoeuvres; 26% were current smokers; 21% of noncurrent smokers were exposed to passive smoking at home; current occupational exposure was low (5%). In summary, the authors found a moderate to high prevalence of potentially modifiable risk factors in a large representative sample of patients hospitalized for a chronic obstructive pulmonary disease exacerbation, suggesting unsatisfactory features in their management.

Efficacy and safety of photodynamic therapy versus Nd-YAG laser resection in NSCLC with airway obstruction.

A prospective controlled randomized trial was performed in order to assess the effectiveness and safety of photodynamic therapy versus laser resection in 31 patients with partial or complete tracheobronchial obstruction due to inoperable non-small cell lung cancer. Fourteen patients received dihaematoporphyrin ether and argon dye laser photoradiation, and 17 patients received Nd-YAG laser resection. Endoluminal obstruction of >75% was found in 77.4% of the patients. Among the symptoms, cough was more severe in the Nd-YAG group (p=0.02). Patients in both groups experienced symptomatic relief after treatment (p=0.003). Patients in the photodynamic therapy (PDT) group showed a significantly longer time until treatment failure (p=0.03) and longer median survival (p=0.007). Bronchitis and photosensitization (both in the PDT group) were the most common adverse effects. There was one death, probably related to treatment, in the PDT group. Photodynamic therapy and neodymium-yttrium aluminium garnet laser resection showed similar effectiveness and safety in the palliation of symptoms. The more prolonged survival in the photodynamic therapy group may have been due to differences in tumour stage between the groups. The degree of obstruction improved after treatment in both groups. In conclusion, photodynamic therapy is a valid method of palliation in partially or totally obstructing non-small cell lung carcinoma.

[Usefulness of home visits in the control and evaluation of the appropriate use of home continuous oxygen therapy]. / Utilidad de la visita a domicilio en el control y valoración del uso apropiado de la oxigenoterapia continua domiciliaria.

The aim of this study was to determine the usefulness of home visits to monitor and evaluate the appropriate use of domiciliary oxygen therapy (DOT). Appropriateness was based on the coincidence of circumstances needed to predict benefit from DOT: appropriate indications correct hypoxemia and patient compliance. All patients receiving DOT residing in the town of L'Hospitalet (Barcelona) in June 1994 were enrolled. During a home visit to each patient a questionnaire was administered and spirometric variables, CO in exhaled air and pulse oximetry were recorded. If DOT was not considered appropriate, the patient was referred to the hospital clinic for reevaluation of the prescription. One hundred twenty-eight patients (74% men) were visited. Mean age was 68 years. Use of DOT was seen to be appropriate in only 26% of patients. The prescription of DOT was considered strictly correct in 73 patients (49%); 13 of them were seen to have continued smoking. Of the 60 remaining patients, hypoxemia was correct with oxygen therapy in 46, and of these only 33 complied with DOT. The home visit combined with hospital monitoring allowed us to withdraw DOT from 20 patients, for whom the indications had been incorrect, and to introduce changes in oxygen supply sources for 16 patients who carried pumps. Fourteen started using a concentrator and 2 began using liquid oxygen. Periodic review is necessary for optimal treatment of DOT. The home visit is a good tool for improving DOT follow-up, as it allows the patient to be assessed in the setting where DOT is really applied. It is a monitoring method that is well accepted by the patient.