Association of dead space fraction to mortality in patients with COVID-19-related ARDS: A historical cohort observational study.

OBJECTIVE: To assess the correlation of dead space fraction (VD/VT) measured through time capnography, corrected minute volume (CMV) and ventilation ratio (VR) with clinical outcomes in COVID-19 patients requiring invasive mechanical ventilation. DESIGN: Observational study of a historical cohort. SETTING: University hospital in Medellin, Colombia. PARTICIPANTS: Patients aged 15 and above with a confirmed COVID-19 diagnosis admitted to the ICU and requiring mechanical ventilation. INTERVENTIONS: Measurement of VD/VT, CMV, and VR in COVID-19 patients. MAIN VARIABLES OF INTEREST: VD/VT, CMV, VR, demographic data, oxygenation indices and ventilatory parameters. RESULTS: During the study period, 1047 COVID-19 patients on mechanical ventilation were analyzed, of whom 446 (42%) died. Deceased patients exhibited a higher prevalence of advanced age and obesity, elevated Charlson index, higher APACHE II and SOFA scores, as well as an increase in VD/VT ratio (0.27 in survivors and 0.31 in deceased) and minute ventilation volume on the first day of mechanical ventilation. The multivariate analysis revealed independent associations to in-hospital mortality, higher VD/VT (HR 1.24; 95%CI 1.003-1.525; p = 0.046), age (HR 1.024; 95%CI 1.014-1.034; p < 0.001), and SOFA score at onset (HR: 1.036; 95%CI: 1.001-1.07; p = 0.017). CONCLUSIONS: VD/VT demonstrated an association with mortality in COVID-19 patients with ARDS on mechanical ventilation. These findings suggest that VD/VT measurement may serve as a severity marker for the disease.

Evaluación de producción de biogás y reducción de carga orgánica de vinazas mediante digestión anaerobia / Biogas production evaluation and reduction of vinasse organic load by anaerobic digestion

RESUMEN La vinaza es un residuo derivado de la producción de alcohol carburante, que posee elevada carga orgánica disuelta (46%), bajo pH que oscila entre 3-5 y alta demanda química de oxigeno (DQO) de 200-300 mgDQO/L, dichas características hacen de la vinaza un potencial contaminante. Hoy en día, se han buscado métodos que contribuyan a un adecuado manejo de este residuo, como su aprovechamiento para generar energía. En esta investigación se determinó el efecto de la concentración de vinaza y el tipo de lodo inoculante sobre la tasa global de producción de biogás, actividad metanogénica y reducción de carga orgánica durante el proceso de digestión anaerobia. Se utilizaron lodos como fuente de inóculo, provenientes de una PTAR, de una laguna de vinaza, y de laguna de oxidación y enfriamiento; la producción de biogás se cuantificó con la técnica de desplazamiento de líquido, se determinó la actividad metanogénica específica (AME), se determinó la tasa de remoción de DQO y sólidos totales y se aislaron microorganismos metanogénicos. Se encontró que la concentración de 90% de vinaza con lodos de la laguna de oxidación obtuvo los mejores rendimientos, se cuantificó 674.5 mL de biogás durante 1 8 días en un volumen de trabajo de 400 mL y se calculó la AME de 0.2 gDQOCH4/gSSV.d. Se demostró que a partir de la digestión anaerobia reduce un 25.2% de la DQO y 22.4% de sólidos; los resultados del análisis microbiológico permitieron evidenciar la presencia de microorganismos metanogénicos en el biorreactor anaerobio.

ABSTRACT Sugarcane vinasse is a residue derived from the production of fuel alcohol, that has a high dissolved organic load (46%), pH ranging from 3 to 5, and chemical oxygen demand (COD) from 200 to 300 mg/l. These characteristics make of the vinasse a potential contaminant. Therefore, methods have been sought that contribute to an adequate management of this waste, such as its use to generate energy. In this research, the process of anaerobic digestion of sugarcane vinasse and sludge as inoculant was evaluated based on the global rate of biogas production, methanogenic activity and reduction of organic load. Different concentrations of vinasse and different sources of sludge were tested; WWTP biosolids, vinasse sludge, and sludge from oxidation and cooling lagoon. Biogas production was quantified by technique liquid displacement, was determined the specific methanogenic activity (SMA), removal of COD and total solids were also determined, and isolation of methanogenic microorganisms. It was determined that the concentration of 90% of vinasse with sludge from the oxidation and cooling lagoon produced the highest yield; 674.5 mL of biogas was quantified during 18 days in a work volume of 400 mL and the SMA of 0.2 g DQOCH4 / gSSV.d was calculated. It was demonstrated that the anaerobic digestion it reduces 25.2% of COD and 22.4% of solids, the results of the microbiological analysis allowed to demonstrate the presence of methanogenic microorganisms in the anaerobic biorreactor.

Características clínicas y demográficas de pacientes con trauma raquimedular Experiencia de seis años / Clinical and demographic characteristics of patients with spinal cord injury Six years experience

Introducción: el trauma raquimedular (TRM) es una entidad potencialmente catastrófica y la información acerca de las características del TRM penetrante relacionadas con violencia, particularmente las heridas por arma de fuego es escasa. Diseño del estudio: estudio de cohorte retrospectiva. Objetivos: determinar las características clínicas y demográficas de la población con TRM atendidas en un hospital de tercer nivel de Medellín. Métodos: revisamos las historias clínicas de los pacientes admitidos con diagnóstico de TRM entre enero de 2005 y diciembre de 2010. Se recolectaron datos con respecto a estancia hospitalaria y en la unidad de cuidados intensivos (UCI), el estado vital y la recuperación neurológica al egreso. Resultados: tuvimos 68 casos de TRM con una frecuencia de 12 casos por 1000 pacientes admitidos a la UCI. La edad media fue de 28 años y 91% fueron del sexo masculino. La principal causa de TRM fue herida por arma de fuego (57%) seguido por accidentes de tránsito (32%). La estancia media de UCI fueron seis días, 56% de los pacientes requirió ventilación mecánica y 37% requirió traqueostomía. El nivel de lesión medular más frecuente fue cervical. La mortalidad hospitalaria fue de 21%, todos estaban con ventilación mecánica y entre más alto fue el nivel de lesión medular mayor era la mortalidad. Conclusiones: nuestra investigación muestra que la población principalmente afectada por el TRM en nuestro medio son los jóvenes y la mortalidad, así como la estancia, complicaciones infecciosas y discapacidad tienen relación directa con el nivel de lesión medular. (Acta Med Colomb2014; 40: 45-50).

Introduction: spinal cord injury (SCI) is a potentially catastrophic entity and information about the characteristics of pervasive SCI related to violence, particularly gunshot wounds, is scarce. Study Design: Retrospective cohort study. Objectives: to determine the clinical and demographic characteristics of the population with SCI attended in a tertiary hospital in Medellin. Methods: The medical records of patients admitted with a diagnosis of SCI between January 2005 and December 2010 were reviewed. Data regarding stay in the hospital and intensive care unit (ICU), vital status and neurological recovery at hospital discharge were collected. Results: there were 68 cases of SCI at a rate of 12 cases per 1000 patients admitted to the ICU. The average age was 28 years and 91% were male. The main cause of SCI was gunshot wounds (57%) followed by traffic accidents (32%). The mean ICU stay was six days, 56% of patients required mechanical ventilation and 37% required tracheostomy. The most common level of spinal cord injury was cervical. Hospital mortality was 21%, all were mechanically ventilated and the higher the level of spinal cord injury, the greater was the mortality. Conclusions: our research shows that people mainly affected by the SCI in our environment are young and mortality, as well as stay, infectious complications and disability are directly related to the level of spinal cord injury. (Acta Med Colomb 2014; 40: 45-50).

Desempeño del APACHE II y el SAPS 3 Adaptación regional en una población de pacientes críticos de Colombia / Performance of APACHE II and SAPS 3 Regional adaptation in a population of critically Ill patients in Colombia

El puntaje fisiológico agudo simplificado, SAPS 3 (del inglés Simplified Acute Physiology Score 3) ha sido recientemente desarrollado con muestras de los cinco continentes, pero no ha sido validado en pacientes de las Unidades de Cuidados Intensivos (UCI) en Colombia. En este trabajo se comparó el desempeño del SAPS 3 con el APACHE II en pacientes colombianos de UCI. Métodos: en una población de una cohorte histórica de pacientes críticos admitidos a una UCI de un hospital universitario, entre enero 1º de 2006 a junio 30 de 2011, se midió el desempeño de los modelos de mortalidad. La probabilidad de muerte hospitalaria fue calculada con el APACHE II y el SAPS 3. Para mejorar la exactitud de los modelos fue realizada una adaptación de primer orden usandola regresión logística del puntaje original para el APACHE II, y para el SAPS 3 se hizo el cálculo de la probabilidad de muerte con las fórmulas para Europa oriental, Centro-Suramérica y Australasia. Resultados: el estudio incluye 2523 pacientes. La mortalidad hospitalaria fue 27%. La discriminación fue aceptable para todos los modelos, más baja para el APACHE II que mejora con la adaptación de 0.74 a 0.78. Para todas las formas de SAPS 3 el área bajo la curva ROC fue de 0.78. La calibración, medida con el estadístico de Hosmer-Lemeshow, fue pobre para el APACHE II, APACHE II adaptado,SAPS 3 adaptado para Centro-Suramérica, y Europa oriental, pero fue buena para el SAPS 3 global y el adaptado para Australasia. Conclusión: en una población de pacientes críticos colombianos, la adaptación logra mejorar la discriminación del APACHE II pero no su calibración. La calibración es adecuada sólo para el SAPS 3 global y el adaptado para Australasia. (Acta Med Colomb 2014; 39: 148-158).

The simplified acute physiological score (SAPS 3) has been recently developed with samples from the five continents, but has not been validated in patients in intensive care units (ICU) in Colombia. In this work the performance of SAPS 3 with APACHE II in Colombian ICU patients was compared. Methods: in a population of a historical cohort of critically ill patients admitted to an ICU of a university hospital between January 1°, 2006 to June 30, 2011, the performance of the mortality models was measured. The probability of hospital death was calculated with APACHE II and SAPS 3. To improve the accuracy of the models, a first order adaptation was realized, using the logistic regression of the original score for the APACHE II, and for SAPS 3 the calculation of the probability of death was done with the formulas for Eastern Europe, Central and South America and Australasia. Results: the study included 2523 patients. Hospital mortality was 27%. Discrimination was acceptable for all models, being lower for APACHE II, which improves with adaptation from 0.74 to 0.78. For all forms of SAPS 3, the area under the ROC curve was 0.78. Calibration, measured with the Hosmer-Lemeshow statistic was poor for the APACHE II, adjusted APACHE II, SAPS 3 adapted to Central South America and Eastern Europe, but it was good for the global SAPS 3 and for the one adapted to Australasia. Conclusion: in a population of Colombian critically ill patients, adaptation manages to improve discrimination of APACHE II but not its calibration. Calibration is appropriate only for the global SAPS 3 and the one adapted to Australasia. (Acta Med Colomb 2014; 39: 148-158).

Pilot study evaluating the safety of a combined central venous catheter and inferior vena cava filter in critically ill patients at high risk of pulmonary embolism.

The objectives of this pilot trial were to assess the safety of a new device for pulmonary embolism (PE) prophylaxis. The device, the Angel Catheter, was placed in eight patients who were in the intensive care unit and were at high risk of PE. The device was inserted at the bedside without fluoroscopic guidance via a femoral venous approach. All eight devices were inserted and subsequently retrieved without complications (follow-up, 33-36 d). One filter trapped a large clot.

The potential impact of admission insulin levels on patient outcome in the intensive care unit.

BACKGROUND: Blood levels of insulin in patients with critical illness at admission to the intensive care unit (ICU) and its association with in-hospital mortality are not fully defined. Our objective was to determine this association in a cohort of patients with critical illness who attended in a mixed ICU. METHODS: Prospective cohort was nested in a randomized clinical trial conducted in a 12-bed mixed ICU in a tertiary hospital in Medellin (Colombia). One hundred sixty consecutively admitted patients, 15 years or older, were analyzed. Blood insulin and blood glucose levels were measured at admission to the ICU, as well as Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores. A logistic regression model was created with in-hospital mortality as the outcome. RESULTS: In-hospital mortality was 57 (35.6%) of 160. Survivors had lower Acute Physiology and Chronic Health Evaluation II (median, 13 vs. 17) and lower insulin levels (median, 6.5 vs. 9 µU/mL) than did nonsurvivors. More women than men died (27 [48.2%] of 56 vs. 30 [28.8%] of 104), and 39% of the deaths (n = 22) occurred in patients with sepsis. Patients with insulin levels greater than 15 µU/mL had a higher mortality rate compared with patients with values of 5 µU/mL to 15 µU/mL (odds ratio, 3.57; 95% confidence interval, 1.18-10.8). CONCLUSION: At admission to the ICU, patients with critical illness showed hyperglycemia and relatively decreased insulin levels. High levels of insulin were independently associated with in-hospital mortality in this study population. LEVEL OF EVIDENCE: Prognostic study, level II.

Strict glycaemic control in patients hospitalised in a mixed medical and surgical intensive care unit: a randomised clinical trial.

INTRODUCTION: Critically ill patients can develop hyperglycaemia even if they do not have diabetes. Intensive insulin therapy decreases morbidity and mortality rates in patients in a surgical intensive care unit (ICU) and decreases morbidity in patients in a medical ICU. The effect of this therapy on patients in a mixed medical/surgical ICU is unknown. Our goal was to assess whether the effect of intensive insulin therapy, compared with standard therapy, decreases morbidity and mortality in patients hospitalised in a mixed ICU. METHODS: This is a prospective, randomised, non-blinded, single-centre clinical trial in a medical/surgical ICU. Patients were randomly assigned to receive either intensive insulin therapy to maintain glucose levels between 80 and 110 mg/dl (4.4 to 6.1 mmol/l) or standard insulin therapy to maintain glucose levels between 180 and 200 mg/dl (10 and 11.1 mmol/l). The primary end point was mortality at 28 days. RESULTS: Over a period of 30 months, 504 patients were enrolled. The 28-day mortality rate was 32.4% (81 of 250) in the standard insulin therapy group and 36.6% (93 of 254) in the intensive insulin therapy group (Relative Risk [RR]: 1.1; 95% confidence interval [CI]: 0.85 to 1.42). The ICU mortality in the standard insulin therapy group was 31.2% (78 of 250) and 33.1% (84 of 254) in the intensive insulin therapy group (RR: 1.06; 95%CI: 0.82 to 1.36). There was no statistically significant reduction in the rate of ICU-acquired infections: 33.2% in the standard insulin therapy group compared with 27.17% in the intensive insulin therapy group (RR: 0.82; 95%CI: 0.63 to 1.07). The rate of hypoglycaemia (< or = 40 mg/dl) was 1.7% in the standard insulin therapy group and 8.5% in the intensive insulin therapy group (RR: 5.04; 95% CI: 1.20 to 21.12). CONCLUSIONS: IIT used to maintain glucose levels within normal limits did not reduce morbidity or mortality of patients admitted to a mixed medical/surgical ICU. Furthermore, this therapy increased the risk of hypoglycaemia. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: 4374-04-13031; 094-2 in 000966421.

Terrorismo biológico: ¿estamos preparados? / Biological terrorism, are we ready?

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El caso de infecciosas: paragonimiasis pulmonar: presentacion de un caso / The case of infectious diseases: pulmonary paragonimiasis: a case report

Se presenta el caso de un hombre de 21 años, natural de Chigorodó, residente en Andes (Antioquia), soldado, que consultó al Hospital Pablo Tobón Uribe con historia de 20 días de evolución de fiebre subjetiva de predominio nocturno, asociada a escalofríos y diaforesis, disnea progresiva y tos seca; los antecedentes personales mostraron ingesta de crustáceos crudos. El diagnóstico de Paragonimiasis fue hecho por biopsia y confirmado en el Instituto de Patología de las Fuerzas Armadas de Estados Unidos, en Washington. El paciente recibió tratamiento con praziquantel y fue dado de alta en buenas condiciones.