ABSTRACT
Rationale: Severe cases of acute respiratory distress syndrome (ARDS) may require prolonged (>28 d) extracorporeal membrane oxygenation (ECMO). In nonresolving disease, recovery is uncertain, and lung transplant may be proposed. Objectives: This study aims to identify the variables influencing survival and to describe the functional status of these patients at 6 months. Methods: This was a retrospective, multicenter, observational cohort study including patients requiring ECMO support for coronavirus disease (COVID-19)-related ARDS for >28 days. Multivariate analysis was performed using Cox regression in preselected variables and in least absolute shrinkage and selection operator selected variables. In a post hoc analysis to account for confounders and differences in awake strategy use by centers, treatment effects of the awake strategy were estimated using an augmented inverse probability weighting estimator with robust standard errors clustered by center. Results: Between March 15, 2020 and March 15, 2021, 120 patients required ECMO for >28 days. Sixty-four patients (53.3%) survived decannulation, 62 (51.7%) were alive at hospital discharge, and 61 (50.8%) were alive at 6-month follow-up. In the multivariate analysis, age (1.09; 95% confidence interval [CI], 1.03-1.15; P = 0.002) and an awake ECMO strategy (defined as the patient being awake, cooperative, and performing rehabilitation and physiotherapy with or without invasive mechanical ventilation at any time during the extracorporeal support) (0.14; 95% CI, 0.03-0.47; P = 0.003) were found to be predictors of hospital survival. At 6 months, 51 (42.5%) patients were at home, 42 (84.3%) of them without oxygen therapy. A cutoff point of 47 ECMO days had a 100% (95% CI, 76.8-100%) sensitivity and 60% (95% CI, 44.3-73.6%) specificity for oxygen therapy at 6 months, with 100% specificity being found in 97 days. Conclusions: Patients with COVID-19 who require ECMO for >28 days can survive with nonlimiting lung impairment. Age and an awake ECMO strategy may be associated with survival. Longer duration of support correlates with need for oxygen therapy at 6 months.
Subject(s)
COVID-19 , Extracorporeal Membrane Oxygenation , Respiratory Distress Syndrome , Humans , Retrospective Studies , Treatment Outcome , Functional Status , COVID-19/therapy , OxygenABSTRACT
OBJETIVO: Definir la complejidad en la atención al final de la vida y los criterios relacionados y proponer, en función de su agrupación por niveles de complejidad, un modelo marco de intervención de los profesionales de la atención primaria de salud y de los recursos paliativos específicos. MATERIAL Y MÉTODOS: Estructura: grupo técnico interdisciplinario de consenso formado por 10 profesionales expertos en la atención al final de la vida (áreas contempladas: atención primaria de salud, paliativa específica, geriátrica, oncológica, trabajo social, bioética y espiritualidad) y la colaboración externa de 2 profesionales expertos en psicooncología y medicina interna. METODOLOGÍA: consenso de los profesionales mediante un procedimiento cualitativo tipo Delphi. Las etapas de consenso corresponden a los apartados de los RESULTADOS: El trabajo se realiza bajo la coordinación de la Sociedad Catalano-Balear de Cuidados Paliativos, la colaboración de la Sociedad Catalana de Medicina Familiar y Comunitaria (CAMFIC) y la dirección del Plan Director Sociosanitario del Departamento de Salud de la Generalitat de Catalunya. RESULTADOS: Definición: la complejidad resulta de la emergencia de procesos que interactúan cumpliendo las propiedades de los sistemas complejos. Modelo de referencia: se parte del modelo de necesidades de pacientes y familias, obteniendo 6 áreas de complejidad: necesidades físicas, psicoemocionales, sociofamiliares, espirituales, relacionadas con la muerte (situación de últimos días y duelo) y aspectos éticos. Áreas y criterios de complejidad: en cada área se describen: conceptos, situaciones habitualmente complejas y criterios de complejidad agrupados en 3 niveles de complejidad (baja, media y alta). Modelo de intervención: la propuesta es baja complejidad, intervención del equipo de referencia y puntualmente del equipo paliativo específico; complejidad media: atención compartida de intensidad pactada; alta complejidad: intervención prioritaria del equipo específico. Ingreso hospitalario. CONCLUSIONES: Resulta necesario diferenciar entre situaciones habitualmente complejas y criterios de complejidad. Aquellas se comportan frecuentemente como proceso emergente, mientras que los criterios corresponderían a la propia emergencia o su resultado. El modelo de intervención propuesto puede resultar útil para facilitar la colaboración asistencial entre los equipos referentes y paliativos específicos, ya que se trata de un modelo corresponsable y dinámico que no parcela la intervención
OBJECTIVE: To define the complexity in end-of-life care and the criteria of complexity, and depending on their grouping within these levels of complexity, to propose a model of intervention that will allow different levels of care to be established, and the framework within which the professionals of primary health care and the palliative team should work. MATERIAL AND METHODS: Structure: a technical and interdisciplinary group of consensus formed by ten professional experts in end of life care in the areas of: community health care, palliative care, geriatric care, oncology, social work, bioethics and spirituality; with external collaboration from two professionals of psycho-oncology and internal medicine. METHODOLOGY: we established a Delphi type qualitative method to obtain a consensus of all the professionals. The different stages of consensus correspond to the points described in the results. The work took place under the coordination of the Catalan-Balearic Society of Palliative Care, with the collaboration of the Catalan Society of Family and Community Medicine (CAMFIC), and the Directorate of the Social-Health Master Plan of the Health Department of the Generalitat of Catalonia. RESULTS: Definition: the complexity is caused by the emerging of processes that, when they interact, fulfil the criteria to be defined complex systems. Reference model: our base model is modelled on the needs of patients and families, thus obtaining six areas of complexity: physical needs, psycho-emotional, socio-family, spiritual, an area related directly with death (situation in the last days, grief), and an area of ethical aspects. Areas and criteria of complexity: in each area the following are obtained: base definitions, situations usually creating complexity, and criteria of complexity grouped in three levels: low medium and high. Model of intervention: the proposal is: low complexity: intervention of the community health care team with occasional intervention by the palliative care team. Medium complexity: shared caring decided between the community health care team and the palliative team. High complexity: main intervention by the palliative team. Hospital admission. CONCLUSIONS: It is necessary to differentiate between situations that are usually complex and the criteria of complexity. The first are those situations that often behave as an emerging process, whereas the criteria of complexity correspond to the actual emergence or its results. The intervention model proposed should improve the collaboration between community care and the palliative care team, as this is a co-responsibility and dynamic model that does not divide the intervention
Subject(s)
Hospice Care , Community Health Services , Primary Health Care , Consensus Development Conferences as TopicABSTRACT
BACKGROUND AND OBJECTIVES: The benefits of high-dose cytarabine, anthracyclines and hematopoietic stem cell transplantation in the treatment of acute myeloid leukemia (AML) are greater in younger rather than in older patients. We assessed the proportion of patients over 60 years with de novo AML who qualified for intensive therapy and determined the feasibility and results of autologous stem cell transplantation (ASCT) in first complete remission (CR). DESIGN AND METHODS: Induction therapy included idarubicin, cytarabine and etoposide. Patients who achieved CR received one cycle of mitoxantrone and cytarabine and ASCT as consolidation therapies. RESULTS: Over a 4-year period, 258 patients were registered of whom 135 (52%) were enrolled for intensive treatment. The CR rate was 61%, advanced age (p=0.033) and unfavorable cytogenetics (p=0.015) emerged as independent negative prognostic factors for CR. The 2-year overall survival (OS) was 23 % (CI 14%-30%) and was poorer in patients with unfavorable cytogenetics (p=0.035), age over 70 years (p=0.019) or leukocytosis (p=0.006). Only 27% of the potential candidates underwent ASCT. The probability of 2-year leukemia-free survival after consolidation was 39% (CI 6%-71%) for these patients and 22% (CI 6% - 39%) for candidate patients not undergoing ASCT (p=0.07). INTERPRETATION AND CONCLUSIONS: Over 25% of the patients 60 to 70 years with de novo AML benefit from standard intensive treatment. In these patients, ASCT has a tolerable toxicity and may have a positive impact on leukemia-free survival.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Hematopoietic Stem Cell Transplantation , Leukemia, Myeloid/therapy , Acute Disease , Age Factors , Aged , Aged, 80 and over , Combined Modality Therapy , Cytarabine/administration & dosage , Disease-Free Survival , Etoposide/administration & dosage , Female , Humans , Idarubicin/administration & dosage , Leukemia, Myeloid/drug therapy , Logistic Models , Male , Middle Aged , Mitoxantrone/administration & dosage , Proportional Hazards Models , Remission Induction , Transplantation, AutologousABSTRACT
The scavenger receptor cysteine-rich superfamily (SRCR-SF) is a highly conserved group of membrane and/or secreted proteins related to the innate and adaptive immune system. Here, we report the cloning of the gene encoding human S4D-SRCRB, a novel soluble member of the SRCR-SF, which is composed of four group B SRCR domains separated by Pro-, Ser- and Thr-rich polypeptides. The longest cDNA sequence found is 2,806 bp in length and encodes a mature protein of 528 aa, with a predicted molecular mass of M(r) 55,600. The S4D-SRCRB gene is located at Chromosome 7q11.23, telomeric to the Williams-Beuren syndrome deletion. It extends over 20 kb and consists of 11 exons, with each SRCR domain being encoded by a single exon. Northern blot analysis indicated that S4D-SRCRB has a broad tissue distribution and is expressed as two major mRNA species: one of 2.8 kb, with a restricted tissue expression pattern (mainly kidney and placenta), and another of 1.5 kb, with a broader distribution. A similar mRNA expression pattern was observed during the analysis of several tumor cell lines. The highest degree of similarity found between S4D-SRCRB and other group B SRCR-SF members was with human DMBT1 (a mosaic protein composed of fourteen SRCR domains, which is involved in innate defense and epithelia polarization) and chicken 18-B (a turpentine-induced soluble acute-phase protein composed of four SRCR domains). Our data indicate that S4D-SRCRB constitutes a novel SRCR-SF member, which could be involved in basic homeostatic functions such as innate host defense.
