Anesthesia and surgery in very precarious conditions. Clinical cases.

We performed herniorrhaphy on 21 children (4 of them infants) and 3 adults, in very precarious conditions, in a hospital in a economically depressed area of the Democratic Republic of Congo. Anesthesia technique used in adults was subarachnoid and intravenous and intramuscular ketamine in children. Ketamine is an irreplaceable anesthetic in many parts of the world without resources, where the minimum safety means are not available. Knowing the simple anesthetic techniques, but with less risk, can also be useful in resourceful places, in unexpected situations. Greater solidarity is needed, both from anesthesia societies and from anesthesiologists, to alleviate the great deficiencies in well-trained professionals and means in places without resources.

Anestesia y cirugía en condiciones muy precarias. Casos clínicos / Anesthesia and surgery in very precarious conditions. Clinical cases

A 21 niños (4 de ellos lactantes) y 3 adultos les fueron realizadas herniorrafias inguinales, en condiciones muy precarias, en un hospital de un área económicamente deprimida de la República Democrática del Congo. Se empleó anestesia subaracnoidea en los adultos y ketamina por vía intravenosa e intramuscular en los niños.La ketamina es un anestésico insustituible en muchos lugares del mundo sin recursos, en los que no se dispone de los mínimos medios de seguridad. Conocer las técnicas anestésicas simples, pero de menor riesgo, puede resultar también útil en sitios con recursos ante situaciones inesperadas. De manera general, hace falta una mayor solidaridad, tanto de las sociedades de anestesia como de los anestesiólogos, para paliar las grandes carencias en medios y profesionales bien formados en lugares sin recursos.(AU)

We performed herniorrhaphy on 21 children (4 of them infants) and 3 adults, in very precarious conditions, in a hospital in a economically depressed area of the Democratic Republic of Congo. Anesthesia technique used in adults was subarachnoid and intravenous and intramuscular ketamine in children.Ketamine is an irreplaceable anesthetic in many parts of the world without resources, where the minimum safety means are not available. Knowing the simple anesthetic techniques, but with less risk, can also be useful in resourceful places, in unexpected situations. Greater solidarity is needed, both from anesthesia societies and from anesthesiologists, to alleviate the great deficiencies in well-trained professionals and means in places without resources.(AU)

Pouteria ramiflora leaf extract on emulgel in wound healing activity in diabetic rats / Ação do extrato de folhas de Pouteria ramiflora em emulgel na atividade de cicatrização de feridas em ratos diabéticos

The genus Pouteria has been studied because it presents various activities, among which is its anti-inflammatory potential. The effects of Pouteria ramiflora Carbopol gel on the healing of skin wounds in diabetic rats were evaluated by microscopic imaging. Streptozotocin was administered intraperitoneally in animals that had fasted for 12 hours, a situation confirmed by the glycemic index (> 240 mg dL-¹). An excision on the back of the animals was performed and three groups were formed: Control (Gel), Ethanolic extract (Ext) and Gel + extract 2% (Ext+gel); the histopathological evaluation occurred on the 7th, 14th, 21st and 30th days after the post-operative period. The results of the phytochemical prospecting of P. ramiflora extract demonstrated the major presence of phenolic compounds and flavonoids; the assessment of the inflammatory infiltrate on the 7th day was higher on group Ext and Ext+gel when compared to group Control; on the 14th day control and Ext (p<0.05). The quantification of fibroblasts was higher on the 7th day among the three treatments, control and Ext (p<0.05), on the 21st day. Angiogenesis showeda higher number of vessels in Ext+gel group (p<0.05) on the 7th day; in Control, Ext and Ext+gel (p<0.05) on the 14th day; and Control and Ext (p<0.05)on the 21st day. The histopathological results showed that the formulation Ext+gel was efficient in tissue reparation and decrease in inflammatory cells on the diabetic's animals.

O gênero Pouteria apresenta várias aplicações terapêuticas e, dentre elas, grande potencial antiflamatório. Os efeitos do gel de Pouteria ramiflora sobre a cicatrização de feridas na pele de ratos diabéticos foram avaliados pela histomorfometria. A estreptozotocina foi administrada por via intraperitoneal em animais após jejum de 12 horas, a confirmação de indução da diabetes foi confirmada pelo índice glicêmico (> 240 mg dL-1). Foi realizada uma incisão no dorso do animal e foram criados 3 grupos de tratamento: controle (gel carbopol), extrato etanólico (Ext) e Gel + extrato etanólico à 2% (Ext+gel); a avaliação histopatológica foi realizada no 7º, 14º, 21º e 30º dias após o período pós operatório. Os resultados da prospecção fitoquímica dos extratos de P. ramiflora demonstraram majoritariamente a presença de compostos fenólicos e flavonóides; o infiltrado inflamatório avaliado no 7º dia foi maior para animais do grupo controle em relação aos grupos Ext (p<0.05) e Ext+gel 2% (p<0.05); no 14º dia o controle e Exp (p<0.05) apresentaram aumento significativo dos infiltrados inflamatórios. A presença de fibroblastos foi elevada no 7º dia em todos os tratamentos. O processo da angiogênese mostrou um maior número de vasos sanguíneos entre os grupos Ext e Ext+gel (p<0.05) no 7º dia; no 14º dia o grupo controle, Ext (p<0.05), Control e Ext+gel (p<0.05) apresentaram aumento de vascularização, e no 21º dia apenas os grupos controle e Ext (p<0.05). Os resultados histopatológicos mostraram que a formulação gel carbopol + extrato etanólico a 2% foi eficiente na reparação de tecidos e na diminuição de células inflamatórias nos animais diabéticos.

Pouteria ramiflora leaf extract on emulgel in wound healing activity in diabetic rats

Abstract The genus Pouteria has been studied because it presents various activities, among which is its anti-inflammatory potential. The effects of Pouteria ramiflora Carbopol gel on the healing of skin wounds in diabetic rats were evaluated by microscopic imaging. Streptozotocin was administered intraperitoneally in animals that had fasted for 12 hours, a situation confirmed by the glycemic index ( 240 mg dL-1). An excision on the back of the animals was performed and three groups were formed: Control (Gel), Ethanolic extract (Ext) and Gel + extract 2% (Ext+gel); the histopathological evaluation occurred on the 7th, 14th, 21st and 30th days after the post-operative period. The results of the phytochemical prospecting of P. ramiflora extract demonstrated the major presence of phenolic compounds and flavonoids; the assessment of the inflammatory infiltrate on the 7th day was higher on group Ext and Ext+gel when compared to group Control; on the 14th day control and Ext (p 0.05). The quantification of fibroblasts was higher on the 7th day among the three treatments, control and Ext (p 0.05), on the 21st day. Angiogenesis showed a higher number of vessels in Ext+gel group (p 0.05) on the 7th day; in Control, Ext and Ext+gel (p 0.05) on the 14th day; and Control and Ext (p 0.05)on the 21st day. The histopathological results showed that the formulation Ext+gel was efficient in tissue reparation and decrease in inflammatory cells on the diabetics animals.

Resumo O gênero Pouteria apresenta várias aplicações terapêuticas e, dentre elas, grande potencial antiflamatório. Os efeitos do gel de Pouteria ramiflora sobre a cicatrização de feridas na pele de ratos diabéticos foram avaliados pela histomorfometria. A estreptozotocina foi administrada por via intraperitoneal em animais após jejum de 12 horas, a confirmação de indução da diabetes foi confirmada pelo índice glicêmico ( 240 mg dL-1). Foi realizada uma incisão no dorso do animal e foram criados 3 grupos de tratamento: controle (gel carbopol), extrato etanólico (Ext) e Gel + extrato etanólico à 2% (Ext+gel); a avaliação histopatológica foi realizada no 7º, 14º, 21º e 30º dias após o período pós operatório. Os resultados da prospecção fitoquímica dos extratos de P. ramiflora demonstraram majoritariamente a presença de compostos fenólicos e flavonóides; o infiltrado inflamatório avaliado no 7º dia foi maior para animais do grupo controle em relação aos grupos Ext (p 0.05) e Ext+gel 2% (p 0.05); no 14º dia o controle e Exp (p 0.05) apresentaram aumento significativo dos infiltrados inflamatórios. A presença de fibroblastos foi elevada no 7º dia em todos os tratamentos. O processo da angiogênese mostrou um maior número de vasos sanguíneos entre os grupos Ext e Ext+gel (p 0.05) no 7º dia; no 14º dia o grupo controle, Ext (p 0.05), Control e Ext+gel (p 0.05) apresentaram aumento de vascularização, e no 21º dia apenas os grupos controle e Ext (p 0.05). Os resultados histopatológicos mostraram que a formulação gel carbopol + extrato etanólico a 2% foi eficiente na reparação de tecidos e na diminuição de células inflamatórias nos animais diabéticos.

Pouteria ramiflora leaf extract on emulgel in wound healing activity in diabetic rats / Ação do extrato de folhas de Pouteria ramiflora em emulgel na atividade de cicatrização de feridas em ratos diabéticos

The genus Pouteria has been studied because it presents various activities, among which is its anti-inflammatory potential. The effects of Pouteria ramiflora Carbopol gel on the healing of skin wounds in diabetic rats were evaluated by microscopic imaging. Streptozotocin was administered intraperitoneally in animals that had fasted for 12 hours, a situation confirmed by the glycemic index (> 240 mg dL-1). An excision on the back of the animals was performed and three groups were formed: Control (Gel), Ethanolic extract (Ext) and Gel + extract 2% (Ext+gel); the histopathological evaluation occurred on the 7th, 14th, 21st and 30th days after the post-operative period. The results of the phytochemical prospecting of P. ramiflora extract demonstrated the major presence of phenolic compounds and flavonoids; the assessment of the inflammatory infiltrate on the 7th day was higher on group Ext and Ext+gel when compared to group Control; on the 14th day control and Ext (p<0.05). The quantification of fibroblasts was higher on the 7th day among the three treatments, control and Ext (p<0.05), on the 21st day. Angiogenesis showed a higher number of vessels in Ext+gel group (p<0.05) on the 7th day; in Control, Ext and Ext+gel (p<0.05) on the 14th day; and Control and Ext (p<0.05)on the 21st day. The histopathological results showed that the formulation Ext+gel was efficient in tissue reparation and decrease in inflammatory cells on the diabetic's animals.

O gênero Pouteria apresenta várias aplicações terapêuticas e, dentre elas, grande potencial antiflamatório. Os efeitos do gel de Pouteria ramiflora sobre a cicatrização de feridas na pele de ratos diabéticos foram avaliados pela histomorfometria. A estreptozotocina foi administrada por via intraperitoneal em animais após jejum de 12 horas, a confirmação de indução da diabetes foi confirmada pelo índice glicêmico (> 240 mg dL-1). Foi realizada uma incisão no dorso do animal e foram criados 3 grupos de tratamento: controle (gel carbopol), extrato etanólico (Ext) e Gel + extrato etanólico à 2% (Ext+gel); a avaliação histopatológica foi realizada no 7º, 14º, 21º e 30º dias após o período pós operatório. Os resultados da prospecção fitoquímica dos extratos de P. ramiflora demonstraram majoritariamente a presença de compostos fenólicos e flavonóides; o infiltrado inflamatório avaliado no 7º dia foi maior para animais do grupo controle em relação aos grupos Ext (p<0.05) e Ext+gel 2% (p<0.05); no 14º dia o controle e Exp (p<0.05) apresentaram aumento significativo dos infiltrados inflamatórios. A presença de fibroblastos foi elevada no 7º dia em todos os tratamentos. O processo da angiogênese mostrou um maior número de vasos sanguíneos entre os grupos Ext e Ext+gel (p<0.05) no 7º dia; no 14º dia o grupo controle, Ext (p<0.05), Control e Ext+gel (p<0.05) apresentaram aumento de vascularização, e no 21º dia apenas os grupos controle e Ext (p<0.05). Os resultados histopatológicos mostraram que a formulação gel carbopol + extrato etanólico a 2% foi eficiente na reparação de tecidos e na diminuição de células inflamatórias nos animais diabéticos.

Pouteria ramiflora leaf extract on emulgel in wound healing activity in diabetic rats.

The genus Pouteria has been studied because it presents various activities, among which is its anti-inflammatory potential. The effects of Pouteria ramiflora Carbopol gel on the healing of skin wounds in diabetic rats were evaluated by microscopic imaging. Streptozotocin was administered intraperitoneally in animals that had fasted for 12 hours, a situation confirmed by the glycemic index (˃ 240 mg dL-1). An excision on the back of the animals was performed and three groups were formed: Control (Gel), Ethanolic extract (Ext) and Gel + extract 2% (Ext+gel); the histopathological evaluation occurred on the 7th, 14th, 21st and 30th days after the post-operative period. The results of the phytochemical prospecting of P. ramiflora extract demonstrated the major presence of phenolic compounds and flavonoids; the assessment of the inflammatory infiltrate on the 7th day was higher on group Ext and Ext+gel when compared to group Control; on the 14th day control and Ext (p<0.05). The quantification of fibroblasts was higher on the 7th day among the three treatments, control and Ext (p<0.05), on the 21st day. Angiogenesis showed a higher number of vessels in Ext+gel group (p<0.05) on the 7th day; in Control, Ext and Ext+gel (p<0.05) on the 14th day; and Control and Ext (p<0.05)on the 21st day. The histopathological results showed that the formulation Ext+gel was efficient in tissue reparation and decrease in inflammatory cells on the diabetic's animals.

Effect of cerebral palsy and dental caries on dental plaque index, salivary parameters and oxidative stress in children and adolescents.

PURPOSE: The aim of the present study was to investigate the effect of cerebral palsy and dental caries on dental plaque index, salivary parameters and oxidative stress in children and adolescents. METHODS: Seventy children and adolescents aged 2-20 years were divided into four groups: neurotypical controls-inactive caries (NCIC; n = 19); neurotypical controls-active caries (NCAC; n = 16); cerebral palsy-inactive caries (CPIC; n = 19); and cerebral palsy-active caries (CPAC; n = 16). The visible dental plaque index was determined after drying the tooth surfaces and without any mechanical or chemical disclosing methods. Salivary pH and buffer capacity were measured 1 hour after collection using a digital pH meter. Saliva was used to evaluate oxidative status based on the levels of reactive species, lipid peroxidation and non-enzymatic antioxidants (reduced glutathione and vitamin C). RESULTS: The CPIC and CPAC groups had lower salivary pH and a higher visible dental plaque index. CP was also associated with an increase in salivary levels of markers of oxidative stress and the modulation of salivary levels of non-enzymatic antioxidants. CONCLUSION: Cerebral palsy exerts an influence on the salivary profile, oral health and oxidative stress. The individuals with CP had more acidic saliva and a higher dental plaque index, which were positively correlated with caries activity. CP was associated with high salivary levels of reactive species and lipid peroxidation, demonstrating an imbalance in salivary redox that was particularly associated with caries activity. These factors facilitate the development of oral diseases in individuals with cerebral palsy.

Iberian consensus on cow's milk allergy: The CIBAL Study

BACKGROUND: The present study explores the professional opinion of a wide range of experts from the Iberian Peninsula (Spain and Portugal) and their degree of consensus about CMPA's prevention, diagnosis, treatment and progression. Material and methodsA 57-item survey divided in four blocks: Prevention (14 items), Diagnosis (10 items), Treatment (19 items) and Progression (14 items) was completed by 160 panellists, experts in CPMA management (116 Spain, 44 Portugal). Each one answered the questionnaire, formulated in Portuguese and Spanish, by individually accessing an online platform in two consecutive rounds. Five possible answers were possible: "completely agree", "agree", "neither agree nor disagree", "disagree" and "completely disagree". A modified Delphi method was used. RESULTS: Consensus (more than 66% agree) was reached in 39 items (68.4%) and Discrepancy (less than 50% agree) in nine items (15.7%). Block separated analysis offers valuable differences regarding consensus. The Prevention block only reached 50%; the Diagnosis block 90%; the Treatment block 73.68%, showing a high degree of agreement on dietary treatment (15/16 items), and discrepancy or less agreement on immunotherapy treatments. The Progression block reached 71.4% consensus with discrepancy with regard to the time to perform oral food challenge and negatives prognosis consequences of accidental milk ingestion. CONCLUSIONS: This study displays the current opinions of a wide group of experts on CMPA from the Iberian Peninsula and evidence discussion lines in CMPA management. The questions on which there were situations of discrepancy, provide us with very useful information for promoting new, rigorous research enabling us to draw conclusions on these controversial aspects

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Posttransplant monomorphic Burkitt's lymphoma: clinical characteristics and outcome of a multicenter series.

Burkitt's monomorphic posttransplant lymphoproliferative disorder (B-PTLD) is an uncommon subtype of PTLD. Owing to the paucity of this complication, clinical characteristics and outcome has not been fully described. Clinical characteristics and outcomes of 20 patients diagnosed with B-PTLD from 10 transplant centers belonging to the GEL/TAMO group were reviewed. Median time from transplant to B-PTLD was 7.2 years. All the cases fulfill the morphologic and genetic criteria of B-PTLD, whereas Epstein-Barr virus (EBV) was detected in 70% of cases. Patients were treated with different chemotherapy combinations, and three patients received upfront rituximab monotherapy. The great majority of patients receiving CHOP-like regimens attained a complete response (CR) (73%), similar to that obtained with dose-intensive chemotherapy (83% CR). In contrast, patients receiving upfront rituximab monotherapy required subsequent chemotherapy. Two patients (10%) died during treatment due to infection. The median progression-free survival and overall survival (OS) were 16 months and 139 months, respectively. When analyzing variables predicting for OS, we found that patients with bone marrow involvement had an adverse prognosis, with a median OS of 6 months (p = 0.008). In conclusion, B-PTLD is an uncommon complication usually associated with EBV infection and with an aggressive clinical course, particularly in patients with bone marrow involvement. High-dose chemoimmunotherapy obtained similar responses to R-CHOP, suggesting that R-CHOP could be an adequate alternative for these patients. In contrast, rituximab monotherapy does not seem to be effective enough to control the disease.

The accuracy of PiCCO® in measuring cardiac output in patients under therapeutic hypothermia: Comparison with transthoracic echocardiography / La exactitud de PiCCO ® para medir el gasto cardíaco en pacientes bajo hipotermia terapéutica: comparación con ecocardiografía transtorácica

Background: Invasive cardiac monitoring using thermodilution methods such as PiCCO® is widely used in critically ill patients and provides a wide range of hemodynamic variables, including cardiac output (CO). However, in post-cardiac arrest patients subjected to therapeutic hypothermia, the low body temperature possibly could interfere with the technique. Transthoracic Doppler echocardiography (ECHO) has long proved its accuracy in estimating CO, and is not influenced by temperature changes. Objective: To assess the accuracy of PiCCO® in measuring CO in patients under therapeutic hypothermia, compared with ECHO. Design and patients: Thirty paired COECHO/COPiCCO measurements were analyzed in 15 patients subjected to hypothermia after cardiac arrest. Eighteen paired measurements were obtained at under 36°C and 12 at ≥36°C. A value of 0.5l/min was considered the maximum accepted difference between the COECHO and COPiCCO values. Results: Under conditions of normothermia (≥36°C), the mean difference between COECHO and COPiCCO was 0.030 l/min, with limits of agreement (−0.22, 0.28) - all of the measurements differing by less than 0.5 l/min. In situations of hypothermia (<36°C), the mean difference in CO measurements was −0.426 l/min, with limits of agreement (−1.60, 0.75), and only 44% (8/18) of the paired measurements fell within the interval (−0.5, 0.5). The calculated temperature cut-off point maximizing specificity was 35.95°C: above this temperature, specificity was 100%, with a false-positive rate of 0%. Conclusions: The results clearly show clinically relevant discordance between COECHO and COPiCCO at temperatures of <36°C, demonstrating the inaccuracy of PiCCO® for cardiac output measurements in hypothermic patients (AU)

Introducción : La monitorización invasiva cardiaca mediante métodos de termodilución, como PiCCO®, es ampliamente utilizada en pacientes críticamente enfermos y proporciona una gran variedad de variables hemodinámicas, como el gasto cardiaco (GC). No obstante, en los pacientes post-paro cardíaco bajo hipotermia terapéutica, la baja temperatura corporal podría interferir con la técnica. La ecocardiografía doppler transtorácica (ECHO) ha demostrado su exactitud en la estimación del GC y no está influenciada por los cambios de temperatura. Objetivo: El objetivo del presente estudio fue evaluar la exactitud de PiCCO® para medir el GC en pacientes bajo hipotermia terapéutica, en comparación con ECHO. Diseño y pacientes: Se analizaron 30 pares de mediciones GC_ECHO/GC_PiCCO en 15 pacientes sometidos a hipotermia después de un paro cardíaco. La máxima diferencia aceptada entre los valores de GC_ECHO y GC_PiCCO se consideró 18 mediciones pareadas se realizaron a menos de 36°C y 12 a ≥36°C. 0,5L/min. Resultados: En la normotermia (≥36°C), la diferencia media entre GC_ECHO y GC_PiCCO fue de 0,030L/min, con límites de concordancia (-0,22; 0,28), todas las medidas difieren menos de 0,5L/min. En la hipotermia (<36°C), la diferencia media de las mediciones fue -0,426L/min con límites de concordancia (-1,60; 0,75) y solo el 44% de las mediciones cayeron en el intervalo (-0,5; 0,5). El límite de temperatura calculado que maximiza la especificidad fue 35,95°C, por encima del cual la especificidad fue del 100% y la tasa de falsos positivos del 0%. Conclusiones: Los resultados muestran claramente una discordancia clínicamente relevante entre GC_ECHO y GC_PiCCO en temperatura <36°C, lo que revela la inexactitud de PiCCO® para las mediciones del gasto cardíaco en pacientes hipotérmicos (AU)

Iberian consensus on cow's milk allergy: The CIBAL Study.

BACKGROUND: The present study explores the professional opinion of a wide range of experts from the Iberian Peninsula (Spain and Portugal) and their degree of consensus about CMPA's prevention, diagnosis, treatment and progression. MATERIAL AND METHODS: A 57-item survey divided in four blocks: Prevention (14 items), Diagnosis (10 items), Treatment (19 items) and Progression (14 items) was completed by 160 panellists, experts in CPMA management (116 Spain, 44 Portugal). Each one answered the questionnaire, formulated in Portuguese and Spanish, by individually accessing an online platform in two consecutive rounds. Five possible answers were possible: "completely agree", "agree", "neither agree nor disagree", "disagree" and "completely disagree". A modified Delphi method was used. RESULTS: Consensus (more than 66% agree) was reached in 39 items (68.4%) and Discrepancy (less than 50% agree) in nine items (15.7%). Block separated analysis offers valuable differences regarding consensus. The Prevention block only reached 50%; the Diagnosis block 90%; the Treatment block 73.68%, showing a high degree of agreement on dietary treatment (15/16 items), and discrepancy or less agreement on immunotherapy treatments. The Progression block reached 71.4% consensus with discrepancy with regard to the time to perform oral food challenge and negatives prognosis consequences of accidental milk ingestion. CONCLUSIONS: This study displays the current opinions of a wide group of experts on CMPA from the Iberian Peninsula and evidence discussion lines in CMPA management. The questions on which there were situations of discrepancy, provide us with very useful information for promoting new, rigorous research enabling us to draw conclusions on these controversial aspects.

A ten-color tube with dried antibody reagents for the screening of hematological malignancies.

INTRODUCTION: The workflow in clinical flow cytometry laboratories must constantly be reviewed to develop technical procedures that improve quality and productivity and reduce costs. Using the Beckman Coulter dry coating technology, we customized a ten-color tube with dried antibody reagents, designated the Duraclone screening tube (DST), for screening hematological malignancies. Here, we compared the applicability, clinical and numerical equivalence, and cost and time required for the technical procedures between the liquid reagents and the DST. METHODS: The DST contains CD4 + Kappa-FITC, CD8 + Lambda-PE, CD3 + CD14-ECD, CD33-PE-Cy5.5, CD20 + CD56-PE-Cy7, CD34-APC, CD19-APC-AlexaFluor700, CD10-APC-AlexaFluor750, CD5-Pacific Blue, and CD45-Krome Orange. We evaluated 20 bone marrow samples, 13 peripheral blood samples, 6 lymph node biopsy samples, 5 fine-needle aspirate samples, 5 cerebrospinal fluid samples, and 1 pleural fluid sample. RESULTS: The DST was useful for more than 60% of our samples. It was able to enumerate the majority of the populations in all types of samples with a statistically acceptable correlation with the liquid reagents. The use of the DST translated into significant time and cost savings of 15.8% and 12.3%, respectively, compared with the use of the liquid reagent. The cost was reduced by $14.36 per sample. CONCLUSIONS: The DST is an efficient solution for screening hematological malignancies with improved quality, productivity, standardization, and sustainability. These improvements could benefit patients by providing faster diagnoses using a higher quality and lower cost reagent.

The accuracy of PiCCO® in measuring cardiac output in patients under therapeutic hypothermia: Comparison with transthoracic echocardiography.

BACKGROUND: Invasive cardiac monitoring using thermodilution methods such as PiCCO® is widely used in critically ill patients and provides a wide range of hemodynamic variables, including cardiac output (CO). However, in post-cardiac arrest patients subjected to therapeutic hypothermia, the low body temperature possibly could interfere with the technique. Transthoracic Doppler echocardiography (ECHO) has long proved its accuracy in estimating CO, and is not influenced by temperature changes. OBJECTIVE: To assess the accuracy of PiCCO® in measuring CO in patients under therapeutic hypothermia, compared with ECHO. DESIGN AND PATIENTS: Thirty paired COECHO/COPiCCO measurements were analyzed in 15 patients subjected to hypothermia after cardiac arrest. Eighteen paired measurements were obtained at under 36°C and 12 at ≥36°C. A value of 0.5l/min was considered the maximum accepted difference between the COECHO and COPiCCO values. RESULTS: Under conditions of normothermia (≥36°C), the mean difference between COECHO and COPiCCO was 0.030 l/min, with limits of agreement (-0.22, 0.28) - all of the measurements differing by less than 0.5 l/min. In situations of hypothermia (<36°C), the mean difference in CO measurements was -0.426 l/min, with limits of agreement (-1.60, 0.75), and only 44% (8/18) of the paired measurements fell within the interval (-0.5, 0.5). The calculated temperature cut-off point maximizing specificity was 35.95°C: above this temperature, specificity was 100%, with a false-positive rate of 0%. CONCLUSIONS: The results clearly show clinically relevant discordance between COECHO and COPiCCO at temperatures of <36°C, demonstrating the inaccuracy of PiCCO® for cardiac output measurements in hypothermic patients.

Radioimmunotherapy-augmented BEAM chemotherapy vs BEAM alone as the high-dose regimen for autologous stem cell transplantation (ASCT) in relapsed follicular lymphoma (FL): a retrospective study of the EBMT Lymphoma Working Party.

Relapse remains the most common cause of treatment failure in patients receiving autologous stem cell transplantation (ASCT) for follicular lymphoma (FL). The aim of this study was to evaluate the effect of adding radioimmunotherapy or rituximab (R) to BEAM (carmustine, etoposide, ara-c, melphalan) high-dose therapy for ASCT in patients with relapsed FL. Using the European Society for Blood and Marrow Transplantation registry, we conducted a cohort comparison of BEAM (n=1973), Zevalin-BEAM (Z-BEAM) (n=207) and R-BEAM (n=179) and also a matched-cohort analysis of BEAM vs Z-BEAM including 282 and 154 patients, respectively. BEAM, Z-BEAM and R-BEAM groups were well balanced for age, time from diagnosis to ASCT and disease status at ASCT. The cumulative incidences of relapse (IR) at 2 years were 34, 34 and 32% for Z-BEAM, R-BEAM and BEAM, respectively. By multivariate analysis, there were no significant differences with Z-BEAM or R-BEAM compared with BEAM for IR, non-relapse mortality, event-free survival or overall survival. With the caveat that the limitations of registry analyses have to be taken into account, this study does not support adding radioimmunotherapy or R to BEAM in ASCT for relapsed FL. However, we cannot rule out the existence a particular subset of patients who could benefit from Z-BEAM conditioning that cannot be identified in our series, and this should be tested in a randomized trial.

Haplo-Cord transplantation compared to haploidentical transplantation with post-transplant cyclophosphamide in patients with AML.

For patients with AML, the best alternative donor remains to be defined. We analyze outcomes of patients who underwent myeloablative umbilical cord blood or haploidentical hemopoietic stem cell transplantation (HSCT) in Spain. Fifty-one patients underwent single umbilical cord blood transplantation supported by a third party donor (Haplo-Cord) between 1999 and 2012, and 36 patients received an haploidentical HSCT with post-transplant cyclophosphamide (PTCY-haplo) between 2012 and 2014 in GETH centers. The Haplo-Cord cohort included a higher proportion of patients with high disease risk index and use of TBI in the conditioning regimen, and hematopoietic cell transplantation-age Comorbidity Age Index was higher in PTCY-haplo patients. Cumulative incidence of neutrophil engraftment was 97% in the Haplo-Cord and 100% in the PTCY-haplo group, achieved in a median of 12 and 17 days, respectively (P=0.01). Grade II-IV acute GvHD rate was significantly higher in the PTCY-haplo group (9.8% vs 29%, P=0.02) as well as chronic GvHD rates (20% vs 38%, P=0.03). With a median follow-up of 61 months for the Haplo-Cord group and 26 months for the PTCY-haplo cohort, overall survival at 2 years was 55% and 59% (P=0.66), event-free survival was 45% vs 56% (P=0.46), relapse rate was 27% vs 21% (P=0.79), and non-relapse mortality was 17% vs 23% (P=0.54), respectively. In this multicenter experience, Haplo-Cord and PTCY-haplo HSCT offer valid alternatives for patients with AML. Neutrophil engraftment was faster in the Haplo-Cord cohort, with similar survival rates, with higher GvHD rates after haploidentical HSCT.

Busulfan-based reduced intensity conditioning regimens for haploidentical transplantation in relapsed/refractory Hodgkin lymphoma: Spanish multicenter experience.

Relapsed or refractory Hodgkin lymphoma (advanced HL) still remains a therapeutic challenge. Recently, unmanipulated haploidentical related donor transplant with reduced conditioning regimen (HAPLO-RIC) and post-transplant cyclophosphamide (PT-Cy) as GvHD prophylaxis has became a promising rescue strategy potentially available to almost every patient. This paper reports our multicenter experience using an IV busulfan-based HAPLO-RIC regimen and PT-Cy in the treatment of 43 patients with advanced HL. Engraftment occurred in 42 patients (97.5%), with a median time to neutrophil and platelet recovery of 18 and 26 days. Cumulative incidences of grades II-IV acute GvHD and chronic GvHD were 39% and 19%, respectively. With a median follow-up of 25.5 months for survivors, 27 patients are alive, with 22 of them disease free. Cumulative incidences of 1-year non-relapse mortality and relapse at 2 years were 21% and 24%, respectively. The estimated 2-year event-free survival (EFS) and overall survival (OS) were 48% and 58%, respectively. CR prior to HAPLO-RIC correlated with better EFS (78.5% vs 33.5%; P=0.015) and OS (86% vs 46%; P=0.044). Our findings further confirm prior reports using HAPLO-RIC in advanced HL in a multicenter approach employing an IV busulfan-based conditioning regimen.

Atypical hemolytic uremic syndrome in intensive care: Case report in an adult / Síndrome hemolítico urémico atípico en cuidados intensivos: caso clínico de un adulto

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Cardiac arrest every other day / / Parada cardíaca cada dos días

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