Tranexamic acid use in severely injured patients, is it always appropriate?

Recently, it has been suggested that tranexamic acid should be administered only in those patients with hyperfibrinolysis determined using viscoelastic assays, as severely injured patients may present with fibrinolytic shutdown. However the last European guidelines on management of major bleeding and coagulopathy following trauma endorse the use of tranexamic acid to the trauma patient who is bleeding or at risk of significant hemorrhage as soon as possible without waiting for viscoelastic results. We present a severely blunt trauma patient treated with on-scene administration of tranexamic acid that developed immediate pulmonary embolism.

Ácido tranexámico en el paciente politraumatizado grave, ¿está siempre indicado? / Tranexamic acid use in severely injured patients, is it always appropriate?

Recientemente se ha sugerido la administración de ácido tranexámico sólo en aquellos pacientes con hiperfibrinólisis documentada con métodos viscoelásticos, ya que los pacientes politraumatizados graves pueden presentar una disminución de la fibrinólisis. Sin embargo, las últimas guías clínicas sobre el manejo de la hemorragia y coagulopatía tras un trauma recomiendan el uso de ácido tranexámico en todo paciente sangrante, o con posibilidad de sangrar, lo más precozmente posible sin esperar los resultados de los métodos viscoelásticos. Presentamos el caso de un trauma cerrado grave que recibió ácido tranexámico prehospitalariamente y desarrolló un embolismo pulmonar inmediato.(AU)

Recently, it has been suggested that tranexamic acid should be administered only in those patients with hyperfibrinolysis determined using viscoelastic assays, as severely injured patients may present with fibrinolytic shutdown. However the last European guidelines on management of major bleeding and coagulopathy following trauma endorse the use of tranexamic acid to the trauma patient who is bleeding or at risk of significant hemorrhage as soon as possible without waiting for viscoelastic results. We present a severely blunt trauma patient treated with on-scene administration of tranexamic acid that developed immediate pulmonary embolism.(AU)

Tranexamic acid use in severely injured patients, is it always appropriate? / Ácido tranexámico en el paciente politraumatizado grave, ¿está siempre indicado?

Recently, it has been suggested that tranexamic acid should be administered only in those patients with hyperfibrinolysis determined using viscoelastic assays, as severely injured patients may present with fibrinolytic shutdown. However the last European guidelines on management of major bleeding and coagulopathy following trauma endorse the use of tranexamic acid to the trauma patient who is bleeding or at risk of significant hemorrhage as soon as possible without waiting for viscoelastic results. We present a severely blunt trauma patient treated with on-scene administration of tranexamic acid that developed immediate pulmonary embolism.

pH-Gated photoresponsive shuttling in a water-soluble pseudorotaxane.

A fluorescent bistable pseudorotaxane was devised and shown to display pH-gated photoresponsive ring shuttling. At pH > 7.5 shuttling does not take place after light stimulation while at pH ≈ 5 the macrocycle is quantitatively translocated.

African histoplasmosis: new clinical and microbiological insights.

African histoplasmosis is defined as the fungal infection caused by Histoplasma capsulatum var. duboisii (Hcd). Studies focused on distinguishing Hcd and H. capsulatum var. capsulatum (Hcc), which coexist in Africa, are scarce or outdated, and African strains are continuously underrepresented. In this work, 13 cases of African patients with histoplasmosis diagnosed in the Spanish Mycology Reference Laboratory have been reviewed showing that 77% had disseminated disease and AIDS as underlying disease although Hcd infection has been classically considered a rare presentation in AIDS patients. Strains isolated from these patients and other clinical and reference strains were studied by assessing classical identification methods and performing a three-loci multi-locus sequence analysis (MLSA). Classical identification methods based on biochemical tests and measurement of yeast size proved to be useless in distinguishing both varieties. The MLSA defined an African cluster, with a strong statistical support, that included all strains with African origin. Finally, mating type was also determined by using molecular methods revealing an unequal mating type distribution in African strains. In conclusion, historical statements and classical identification methods were useless to distinguish between varieties, whereas molecular analyses revealed that all strains with African origin grouped together suggesting that traditional classification should be revised. Further investigation is required in order to unravel traditional concepts about Hcd infection and support results obtained in this work.

Development and Validation of a High-Resolution Melting Assay To Detect Azole Resistance in Aspergillus fumigatus.

The global emergence of azole-resistant Aspergillus fumigatus strains is a growing public health concern. Different patterns of azole resistance are linked to mutations in cyp51A Therefore, accurate characterization of the mechanisms underlying azole resistance is critical to guide selection of the most appropriate antifungal agent for patients with aspergillosis. This study describes a new sequencing-free molecular screening tool for early detection of the most frequent mutations known to be associated with azole resistance in A. fumigatus PCRs targeting cyp51A mutations at positions G54, Y121, G448, and M220 and targeting different tandem repeats (TRs) in the promoter region were designed. All PCRs were performed simultaneously, using the same cycling conditions. Amplicons were then distinguished using a high-resolution melting assay. For standardization, 30 well-characterized azole-resistant A. fumigatus strains were used, yielding melting curve clusters for different resistance mechanisms for each target and allowing detection of the most frequent azole resistance mutations, i.e., G54E, G54V, G54R, G54W, Y121F, M220V, M220I, M220T, M220K, and G448S, and the tandem repeats TR34, TR46, and TR53 Validation of the method was performed using a blind panel of 80 A. fumigatus azole-susceptible or azole-resistant strains. All strains included in the blind panel were properly classified as susceptible or resistant with the developed method. The implementation of this screening method can reduce the time needed for the detection of azole-resistant A. fumigatus isolates and therefore facilitate selection of the best antifungal therapy in patients with aspergillosis.

A blue 4',7-diaminoflavylium cation showing an extended pH range stability.

The introduction of two amine substituents in 4' and 7 positions, leads to the formation of a blue flavylium cation, 7-(N,N'-diethylamino)-2-(9-julolidine)-1-benzopyrilium, which is extremely stable across a wide acidic pH range. The kinetic and thermodynamic constants of the multistate system have been calculated by studying the relaxation kinetics after equilibrium perturbation by addition of base (direct pH jumps) or acid (reverse pH jumps). Except for the cis-chalcone, which is an elusive species, the relative energy levels of the other species could be calculated and a global energy level diagram constructed. The diagram explains that the stability of the diamino compound is due to the high energy level of the hemiketal species, which is difficult to access in acidic medium.

Burden of serious fungal infections in Spain.

Estimates of the incidence and prevalence of serious fungal infections, based on epidemiological data, are essential in order to inform public health priorities given the lack of resources dedicated to the diagnosis and treatment of these serious fungal diseases. However, epidemiology of these infections is largely unknown, except for candidaemia and cryptococcosis. The aim of this work is to calculate the burden of serious fungal infections in Spain. All published epidemiology papers reporting fungal infection rates from Spain were identified. Where no data existed, we used specific populations at risk and fungal infection frequencies in those populations to estimate national incidence or prevalence, depending on the condition. Around 8.1 million people suffer a fungal infection every year. Most of them are skin or mucosal infections causing no deaths. Candidaemia is more common than in other European countries and has risen by 1.88-fold in frequency in the last decade (8.1 cases × 100,000). Good estimates of invasive aspergillosis (2.75 cases × 100,000) and mucormycosis (0.04 × 100,000) are available. Fungal infections with a high mortality such as invasive aspergillosis, candidaemia, Pneumocystis pneumonia and mucormycosis are not numerous in Spain, but they affect those with severe underlying diseases and are therefore linked to poor outcomes. Additional studies are required, especially for high burden diseases such as recurrent thrush in women (∼9000 cases × 100,000 women), allergic bronchopulmonary aspergillosis (126 cases × 100,000) and severe asthma with fungal sensitisation (198 cases × 100,000).

Clinical validation of a multiplex real-time PCR assay for detection of invasive candidiasis in intensive care unit patients.

BACKGROUND: New techniques, such as those based on multiplex quantitative real-time PCR (MRT-PCR), can improve the detection of invasive candidiasis (IC). METHODS: We prospectively studied 63 intensive care unit patients with suspected IC and 40 healthy controls. Blood cultures and MRT-PCR were performed at day 0 and +2, +7, +14 and +21 days in all patients. In addition, ß-d-glucan (BDG) and Candida albicans germ tube antibody (CAGTA) were quantified. RESULTS: IC was confirmed in 27 patients. Colonization was significantly higher in patients with IC (96% versus 64%, P = 0.002). The sensitivity, specificity, positive predictive value and negative predictive value of MRT-PCR for the diagnosis of IC were 96.3%, 97.3%, 92.8% and 98.7%, respectively. The positive predictive value and specificity were significantly higher for MRT-PCR than for BDG and CATGA. MRT-PCR performed very well, especially in deep-seated IC (sensitivity 90.9% versus 45.4% for blood culture; P = 0.06). As regards the most appropriate clinical sample for DNA amplification, in this study whole blood and serum presented similar results. CONCLUSIONS: MRT-PCR appears to be a useful test for confirming a diagnosis of IC in critically ill patients, especially in those with deep-seated disease. Its high sensitivity and positive predictive value make it a much more efficient tool for the management of IC than other diagnostic procedures and clinical scores.

Manejo de fuga aérea intraoperatoria en cirugía ortognática. A propósito de un caso / No disponible

No disponible

A single nucleotide change in Hop stunt viroid modulates citrus cachexia symptoms.

Cachexia disease of citrus is caused by Hop stunt viroid (HSVd). In citrus, pathogenic and non-pathogenic strains differ by a "cachexia expression motif" of five to six nucleotides located in the variable domain of the proposed rod-like secondary structure. Here, site-directed mutants were generated to investigate if all these nucleotides were required for infectivity and/or symptom expression. Specifically an artificial cachexia inducing mutant M0 was generated by introducing the six nucleotides changes of the "cachexia expression motif" into a non-pathogenic sequence variant and M0 was used as a template to systematically restore some of the introduced changes. The resulting mutants in which specific changes introduced to generate M0, were restored presented a variety of responses: (i) M1, obtained by introducing two insertions forming a base-pair, was infectious but non-pathogenic; (ii) M2, obtained by introducing an insertion and restoring a substitution, presented low infectivity and the resulting progeny reverted to M0; (iii) M3, obtained by restoring a single substitution in the lower strand of the viroid secondary structure, was infectious but induced only mild cachexia symptoms; (iv) M4, obtained by restoring a single substitution in the upper strand of the viroid secondary structure, was non-infectious. These results confirm that the "cachexia expression motif" plays a major role in inciting cachexia symptoms, and that subtle changes within this motif affect symptom severity and may even suppress symptom expression.

El reflujo de sangre por el catéter al intentar canalizar la vena subclavia no es un signo fiable en caso de hemotórax / Subclavian venous reflux is not a reliable test of catheterization in cases of hemothorax

Un varón de 36 años, tras un accidente de tráfico, presentaba un traumatismo torácico, lesión neurovascular y de partes blandas del brazo izquierdo y lesiones en el macizo facial y en las extremidades. Estaba inestable hemodinámicamente, con mala respuesta a la reposición de volemia y administración de fármacos vasoactivos. Ante la sospecha de un neumotórax se colocó un tubo de tórax en el hemitórax izquierdo por el cual drenaron 1.500 ml de sangre. En la radiografía de tórax se apreció un hemotórax y contusión pulmonar izquierda, sin fracturas costales asociadas. Se intentó canalizar la vena subclavia izquierda, y dado que refluía sangre por el extremo distal del catéter, se transfundió sangre por él. El paciente continuaba muy inestable y por el tubo de tórax drenaron otros 1.000 ml de sangre. Se realizó una toracotomía exploradora que evidenció un desgarro de la vena subclavia, el catéter venoso en la cavidad pleural y fractura de la primera costilla izquierda. En los traumatismos torácicos con hemotórax, al canalizar la vena subclavia ipsilateral el reflujo de sangre por el catéter no es un signo seguro de colocación correcta. Hay que recurrir a otros métodos de comprobación como la morfología de la onda de presión, la radiografía con contraste por el catéter o la electrocardiografía intracavitaria mediante fiador metálico a través del catéter. Si hay una fractura de la primera costilla, que puede pasar desapercibida en la radiografía de tórax, es frecuente la lesión vascular asociada que provoca el hemotórax y ser el origen de una falsa vía al colocar un catéter subclavio (AU)

[Blood reflux through the catheter when trying catheterization of the subclavian vein is not a reliable sign in case of hemothorax]. / El reflujo de sangre por el catéter al intentar canalizar la vena subclavia no es un signo fiable en caso de hemotórax.

A 36-year-old man suffered chest and neurovascular trauma, soft-tissue injury to the left arm, and trauma to facial bones and extremities. He was hemodynamically unstable and responded poorly to blood transfusion and vasoactive medication. Pneumothorax was suspected. When a tube was inserted into the left hemithorax, 1500 mL of blood was drained. A chest film revealed hemothorax and a contusion on the left lung, but no rib fractures. An attempt to catheterize the left subclavian vein yielded reflux, and blood was then transfused. The patient continued to be highly unstable and an additional 1000 mL of blood was drained. Exploratory thoracotomy revealed a ruptured subclavian vein, location of the venous catheter in the pleural cavity, and a fracture of the first left rib. After chest injury leading to hemothorax, reflux upon catheterization of the ipsilateral subclavian vein is not a sure sign of correct tip placement. Additional means for checking placement, such as assessing pressure wave morphology, should be used. A fracture of the first rib, which may not be evident on a chest x-ray, often causes a vascular lesion and thoracic hemorrhage. Incorrect insertion of a subclavian catheter may then follow.

Compresión de la vena umbilical después de una rotura prematura de membranas en la semana 31 / Compression of the umbilical vein after premature rupture of the membranes in the 31 weeks

Objetivo: Estudio detallado mediante ultrasonidos de la enfermedad asociada a una hemorragia vaginal en una amniorrexis prematura.Sujetos y método: Se examinó ecográficamente una gestación en una diabética tipo 1 que presentó una amniorrexis prematura en la semana 31 y hemorragia vaginal.Resultados: En la inserción placentaria del cordón se observa una brida amniótica que rodea y estrangula parcialmente la vena umbilical. Esta brida provocó un desprendimiento periférico parcial de la placenta.Mediante cesárea se confirmó el diagnóstico y se extrajo un recién nacido en buen estado.Conclusión: En una amniorrexis, en una gestación prematura, es aconsejable una exploración ecográfica detallada antes de decidir la conducta a seguir. (AU)