[Improving the outcomes in spontaneous subarachnoid haemorrhage: the EHSA project]. / Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA.

AIM: To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgical management of spontaneous subarachnoid haemorrhages (SAH). PATIENTS AND METHODS A prospective, longitudinal cohort study was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 public hospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acute haemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medical and surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latter was then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due to rebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentially avoidable deaths. RESULTS: A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155 patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension, coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. CONCLUSIONS: Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors.

Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA / Improving the outcomes in spontaneous subarachnoid haemorrhage: The Ehsa project

Objetivo. Investigar nuestras prácticas clínicas, a fin de identificar oportunidades de mejora en el manejo medicoquirúrgicode las hemorragias subaracnoideas (HSA) espontáneas. Pacientes y métodos. Estudio de cohortes, longitudinal,prospectivo, de las HSA atendidas consecutivamente en los servicios de cuidados críticos y urgencias de 29 hospitales públicosde Andalucía durante 20 meses, de 2000 a 2002. Se consideraron HSA los accidentes cerebrovasculares hemorrágicosagudos con este diagnóstico tomográfico. Se analizaron los resultados a 12 meses y el manejo asistencial (terapéutica médicay quirúrgica, técnicas diagnósticas, tiempos asistenciales y complicaciones neurológicas específicas), comparándolo conlas prácticas clínicas que la evidencia científica ha demostrado de mayor utilidad. Se catalogaron como muertes potencialmenteevitables los óbitos por resangrado en pacientes sin estudio arteriográfico o sin exclusión del aneurisma. Resultados.Se incluyeron 506 HSA. Se perdió durante el seguimiento el 5% de la muestra. Fallecieron 155 enfermos. Las variables no modificablesde riesgo independiente para la mortalidad fueron: edad, género masculino, antecedente de hipertensión arterial,coma a la recepción hospitalaria e hidrocefalia. Las variables influenciables de riesgo independiente para fallecer resultaronser: ausencia de analgesia urgente, carencia de diagnóstico arteriográfico, aparición de deterioro neurológico isquémico yresangrado. El 20% de la mortalidad global podría considerarse potencialmente evitable. Conclusiones. Aunque la letalidades mayoritariamente dependiente de variables médicamente no influenciables (sexo, edad, antecedentes, gravedad clínica ehidrocefalia), los decesos, en un 20%, están asociados a factores modificables (AU)

Aim. To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgicalmanagement of spontaneous subarachnoid haemorrhages (SAH). Patients and methods. A prospective, longitudinal cohortstudy was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 publichospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acutehaemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medicaland surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latterwas then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due torebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentiallyavoidable deaths. Results. A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension,coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. Conclusions. Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors (AU)

[Immunosuppressive treatment due to paraquat poisoning]. / Tratamiento inmunosupresor en las intoxicaciones por paraquat.

Paraquat is the most important member of the bipyridyl compound. It is directly caustic in nature and it exerts its herbicidal activity by inhibiting the reduction of NADP to NADPH during photosynthesis, a process in which superoxide, singlet oxygen, hydroxyl, and peroxide radicals are formed. Human tissue toxicity likely results from a similar oxidative mechanism. After oxidative destruction, recruitment of inflammatory cells leads to late onset and irreversible pulmonary fibrosis. Ingestion greater than 20-40 mg/kg of paraquat concentrate should be aggressively managed with the administration of intestinal decontaminants and hemoperfusion. Low-inspired oxygen therapy should be given until it becomes impractical in the face of hypoxemia. Administration of immunodepressive therapy, steroids and cyclophosphamide, should be considered. In addition, there should be intermittent assessment of pulmonary function and of plasma and urinary concentrations of paraquat.

Tratamiento inmunosupresor en las intoxicaciones por paraquat / Immunosuppressive treatment due to paraquat poisoning

El paraquat es el agente más importante de la familia de los biperidilos. Es directamente cáustico en la naturaleza, su actividad es herbicida mediante la reducción del NADP a NADPH durante la fotosíntesis, un proceso de superoxidación que genera radicales oxi, hidroxil y radicales peróxidos. La toxicidad en tejidos humanos resulta de forma parecida por la alteración del proceso oxidativo. Tras la destrucción oxidativa, el reclutamiento de las células inflamatorias conducen a un proceso tardío de fibrosis pulmonar. La ingesta mayor de 20-40 mg/kg de concentrado de paraquat requiere de un tratamiento agresivo con descontaminación intestinal y hemoperfusión. Igualmente, la limitación del aporte de oxígeno a bajo flujo según la hipoxemia tolerable. La administración de terapia inmunosupresora con esteroides y ciclofosfamida debe ser considerada. Igualmente debe ser controlada de forma intermitente la función pulmonar y los niveles de paraquat en plasma y orina

Paraquat is the most important member of the bipyridyl compound. It is directly caustic in nature and it exerts its herbicidal activity by inhibiting the reduction of NADP to NADPH during photosynthesis, a process in which superoxide, singlet oxygen, hydroxyl, and peroxide radicals are formed. Human tissue toxicity likely results from a similar oxidative mechanism. After oxidative destruction, recruitment of inflammatory cells leads to late onset and irreversible pulmonary fibrosis. Ingestion greater than 20-40 mg/kg of paraquat concentrate should be aggressively managed with the administration of intestinal decontaminants and hemoperfusion. Low-inspired oxygen therapy should be given until it becomes impractical in the face of hypoxemia. Administration of immunodepressive therapy, steroids and cyclophosphamide, should be considered. In addition, there should be intermittent assessment of pulmonary function and of plasma and urinary concentrations of paraquat

Pleurodesis con sangre autóloga. Un nuevo concento en el tratamiento del neumotórax de repetición en el SDRA / No disponible

Objetivo: El neumotórax se encuentra presente como complicación frecuente en el síndrome de distres respiratorio agudo (SDRA). La fuga aérea persistente (FAP) prolonga la resolución del neumotórax en una 2% de los casos de SDRA, aumentando la tasa de mortalidad en un 26%. La Pleurodesis con Sangre Autóloga (PSA) en un método efectivo en los casos de cirugía oncológica pulmonar con amplias resecciones. El objetivo de este estudio es comparar la PSA con el drenaje convencional con sello de agua exclusivamente en el manejo del al FAP en el SDRA, en pacientes con neumotórax. Diseño: Caso-control, prospectivo, no randomizado, comparando dos grupos sometidos a matching artificial apareados 1:1. Lugar: Universidad de Granada, Departamento de Medicina y Unidad de Cuidados Intensivos de Almería. Pacientes: Dos grupos de 27 pacientes, todos con SDRA, neumotórax y FAP. Intervención: Un grupo ha recibido tratamiento convencional mientras que el otro se ha sometido a PSA. Resultados principales: La gravedad de los pacientes en ambos grupos es homogénea, mostrada mediante sexo, edad, escalas de Murria, Marshall y Apache II, así como las etiologías del SRDA. Los pacientes en el grupo de PSA tienen una menor estancia en UCI, menor tiempo de weaning y una menor tasa de mortalidad. Las diferencias medias entre ambos grupos fueron 11 días menos en el tiempo de weaning (odds ratioajustada de 0,1) y 9 menos días de tiempo de estancia en UCI (odds ratio ajustada de 0.24). Las tasas de mortalidad en el grupo de PSA y el grupo control fueron 3,7% frente a un 29,6% respectivamente (odds ratioajustada de 0.6). Conclusiones: El uso de PSA hace posible una disminución en los tiempos de ventilación mecánica así como una menor estancia en UCI junto a una optimización de la recuperación funcional y un decremento de la mortalidad (AU)

Pleurodesis with autologous blood

Objective: Pneumothorax is present as a frequent complication in Acute Respiratory Distress Syndrome (ARDS). Persistent air leak (PAL) prolongs pneumothorax in 2% of cases of ARDS, increasing the rate of mortality by 26%. Pleurodesis using autologous blood (PAB) is an effective method in cases of oncological pulmonary surgery. The goal of this study is to compare PAB with the conventional drain and water seal in the management of PAL in ARDS patients with pneumothorax. Design: Case-control, prospective, non-randomised study, comparing two groups subjected to artificial pairing 1:1. Setting: University of Granada, Department of Medicine and Intensive Care Unit, Almeria. Patients: Two groups of 27 patients, all with ARDS, pneumothorax and PAL. Interventions: One group which had received conventional treatment while the other received PAB. Main results: The server of the conditions of both groups is homogeneous, shown by sex, age, Murray, Marshall and Apache II scores, and aetiology of ARDS The patients in the PAB group had a shorter stay in ICU, shorter weaning time and lower death rate. The average difference between the groups is 11 day less waning time (adjusted odds ratio 0.1), and 9 days less on average spent in the Intensive Care Unit (ICU) (adjusted odds ratio 0,24). The death rates in the PAB group and the control group were 3,7% versus 29,6% respectively (adjusted odds ratio 0.6). Conclusions: The use of PAB makes possible a decrease in the ventilator weaning time and shorter stay in ICU with a resulting increase in functional recuperation and decrease in patient mortality (AU)

[The EHSA project: the study of spontaneous subarachnoid haemorrhages in Andalusia. Incidence and results]. / Proyecto EHSA: estudio de hemorragias subaracnoideas espontáneas en Andalucia. Incidencia y resultados.

AIM: To evaluate the incidence and results of spontaneous subarachnoid haemorrhages (SAH) in Andalusia. PATIENTS AND METHODS: We conducted a longitudinal prospective study of the cases of SAH attended in 28 hospitals in Andalusia over a three month period in 2000. SAH was defined as cases of acute haemorrhagic strokes diagnosed by tomography. The gross incidence rate (GR) was determined from census information from the Instituto Andaluz de Estad stica. Standard rates (SR) were estimated with relation to the European population. Results were evaluated on hospital discharge according to the Glasgow Outcome Score (GOS) and at 12 months, according the Barthel index (BI). RESULTS: The GR per 100,000 inhabitants/year was found to be 5.7 cases and the SR was 5.8. A comparison of incidences by province or sex showed no statistically significant differences. The period of maximum risk was the age bracket between 55 74 years (GR: 14.1). The acute fatality GR and SR rose to 1.9 per 100,000 inhabitants and year. Mortality was concentrated in a statistically significant way (p< 0.01) among those over the age of 65; sex did not exert any influence, but clinical gravity (p< 0.001) and the amount of bleeding did (p< 0.005). CONCLUSIONS: The incidence of spontaneous SAH in Andalusia was found to be within the average rates. Unfavourable results were high, although similar to those in other series. Fatality is significantly associated with factors that cannot be modified medically (age, clinical gravity and volume of bleeding)

Proyecto EHSA: estudio de hemorragias subaracnoideas espontáneas en Andalucía. Incidencia y resultados / The EHSA project: the study of spontaneous subarachnoid haemorrhages in Andalusia. Incidence and results

Objetivo. Valorar la incidencia y resultados de las hemorragias subaracnoideas (HSA) espontáneas en Andalucía. Pacientes y métodos. Estudio longitudinal, prospectivo, de las HSA asistidas en 28 hospitales de Andalucía, durante tres meses del año 2000. Se consideraron HSA los ictus hemorrágicos agudos con este diagnóstico tomográfico. La incidencia bruta (TB) se estableció mediante la información censal del Instituto Andaluz de Estadística. Las tasas estandarizadas (TEE) se estimaron con relación a la población europea. Los resultados se valoraron al alta hospitalaria según el GOS (del inglés, Glasgow Outcome Score) y a los 12 meses, según el índice de Barthel (IB). Resultados. La TB por 100.000 habitantes/año se situó en 5,7 casos y la TEE en 5,8. La comparación de incidencias según provincia o sexo no mostró diferencias estadísticamente significativas. El período de máximo riesgo corresponde al intervalo 55-74 años (TB: 14,1). La TB y TEE de letalidad aguda coincidió en 1,5. A los 12 meses, la TB y TEE de letalidad ascendió a 1,9 por 100.000 habitantes y año. La mortalidad se concentró de forma estadísticamente significativa (p< 0,01) entre los mayores de 65 años; no influyó el sexo, pero sí la gravedad clínica (p< 0,001) y la cuantía del sangrado (p< 0,005). Conclusiones. La incidencia de las HSA espontáneas en Andalucía se sitúa en tasas medias. La proporción de resultados desfavorables es elevada, aunque similar a la de otras series. La letalidad se asocia significativamente a factores (edad, gravedad clínica y volumen de sangrado) no modificables médicamente (AU)

Aim. To evaluate the incidence and results of spontaneous subarachnoid haemorrhages (SAH) in Andalusia. Patients and methods. We conducted a longitudinal prospective study of the cases of SAH attended in 28 hospitals in Andalusia over a threemonth period in 2000. SAH was defined as cases of acute haemorrhagic strokes diagnosed by tomography. The gross incidence rate (GR) was determined from census information from the Instituto Andaluz de Estadística. Standard rates (SR) were estimated with relation to the European population. Results were evaluated on hospital discharge according to the Glasgow Outcome Score (GOS) and at 12 months, according the Barthel index (BI). Results. The GR per 100,000 inhabitants/year was found to be 5.7 cases and the SR was 5.8. A comparison of incidences by province or sex showed no statistically significant differences. The period of maximum risk was the age bracket between 55-74 years (GR: 14.1). The acute fatality GR and SR rose to 1.9 per 100,000 inhabitants and year. Mortality was concentrated in a statistically significant way (p< 0.01) among those over the age of 65; sex did not exert any influence, but clinical gravity (p< 0.001) and the amount of bleeding did (p< 0.005). Conclusions. The incidence of spontaneous SAH in Andalusia was found to be within the average rates. Unfavourable results were high, although similar to those in other series. Fatality is significantly associated with factors that cannot be modified medically (age, clinical gravity and volume of bleeding) (AU)

Síndrome de Twiddler: dos casos con distinto eje de rotación / Twiddler´s syndrome: two cases with different rotation axes

El síndrome de Twiddler es una rara complicación de los pacientes portadores de marcapasos, que fue descrito en 1964 por Bayliss et al como "rotación espontánea subconsciente, inadvertida o deliberada, del generador por parte del paciente, dando lugar a un desplazamiento y mal funcionamiento del marcapasos". Presentamos dos casos clínicos con este síndrome, que presentan la particularidad de estar producidos por rotación del marcapasos sobre dos ejes diferentes. En ambos casos pudo identificarse un factor de riesgo común, y los dos se solucionaron con una reintervención quirúrgica (AU)