Usefulness of severity scales for cardiogenic shock in-hospital mortality. Proposal for a new prognostic model.

Cardiogenic shock (CS) is a condition comprising multiple etiologies, which associates high mortality rates. Some scoring systems have been shown to be good predictors of hospital mortality in patients admitted to Critical Care Units (CCU). The main objective of this study is to analyze their usefulness and validity in a cohort of CS patients. METHODS: Observational unicentric study of a cohort of CS patients. SOFA, SAPS II and APACHE II scores were calculated in the first 24 h of CCU admission. RESULTS: 130 patients with CS were included. SOFA, SAPS II and APACHE II scores revealed good discrimination for hospital mortality: (AUC) ROC values (AUC: 0.711, 0.752 and 0.742 respectively; P = .6). Calibration, estimated by the Hosmer-Lemeshow test, was adequate in all cases. Acute coronary syndrome, lactate serum values, SAPS II score and vasoactive inotropic score (VIS) were found to be independent predictors for mortality, upon ICU admission. With these variables, a specific prognostic indicator was developed (SAPS-2-LIVE), which improved predictive capability for mortality in our series (AUC) ROC, 0.825 (95% CI 0.752-0.89). CONCLUSION: In this contemporary CS cohort, the aforementioned scores have been shown to have good predictive ability for hospital mortality. These findings could contribute to a more accurate risk stratification in CS.

Utilidad de las escalas de gravedad en la predicción de mortalidad intrahospitalaria en el shock cardiogénico. Propuesta de un nuevo modelo pronóstico / Usefulness of severity scales for cardiogenic shock in-hospital mortality. Proposal for a new prognostic model

El shock cardiogénico (SC) es una entidad que comprende múltiples etiologías y asocia elevada mortalidad. Algunas escalas de gravedad han demostrado ser buenos predictores de mortalidad hospitalaria en pacientes ingresados en Unidades de Cuidados Intensivos (UCI). El objetivo principal de este estudio es analizar su utilidad y validez en una cohorte de pacientes en SC. Métodos: Estudio observacional unicéntrico. Se calcularon las escalas SOFA, SAPSII y APACHEII en las primeras 24horas de ingreso en UCI. Resultados: Se incluyeron 130 pacientes con SC. Las escalas SOFA, SAPSII y APACHEII mostraron buena discriminación para la mortalidad hospitalaria, obteniendo valores de área bajo la curva (AUC) ROC similares (AUC: 0,711, 0,752 y 0,742, respectivamente; p=0,6). La calibración, estimada por el test de Hosmer-Lemeshow, fue adecuada en todos los casos, SOFA (p=0,787), SAPSII (p=0,078) y APACHEII (p=0,522). Resultaron: predictores independientes de mortalidad intrahospitalaria: el síndrome coronario agudo (SCA), los valores de lactato sérico, el SAPSII y el índice de vasoactivos inotrópicos (VIS) en las primeras 24horas de ingreso en UCI.Con estas variables se desarrolló un indicador pronóstico específico para el SC (SAPS-2-LIVE) que mejora la capacidad predictiva de mortalidad en nuestra serie (AUC) ROC, 0,825 (IC 95% 0,752-0,89). Conclusión: En esta cohorte contemporánea de SC, las escalas SOFA, SAPSII y APACHEII han demostrado una buena capacidad de predicción de mortalidad hospitalaria. Estos hallazgos podrían contribuir a una mejor estratificación del riesgo en el SC.(AU)

Cardiogenic shock (CS) is a condition comprising multiple etiologies, which associates high mortality rates. Some scoring systems have been shown to be good predictors of hospital mortality in patients admitted to Critical Care Units (CCU). The main objective of this study is to analyze their usefulness and validity in a cohort of CS patients. Methods: Observational unicentric study of a cohort of CS patients. SOFA, SAPSII and APACHEII scores were calculated in the first 24hours of CCU admission. Results: 130 patients with CS were included. SOFA, SAPSII and APACHEII scores revealed good discrimination for hospital mortality: (AUC) ROC values (AUC: 0.711, 0.752 and 0.742 respectively; p=0.6). Calibration, estimated by the Hosmer-Lemeshow test, was adequate in all cases.Acute coronary syndrome, lactate serum values, SAPSII score and vasoactive inotropic score (VIS) were found to be independent predictors for mortality, upon ICU admission. With these variables, a specific prognostic indicator was developed (SAPS-2-LIVE), which improved predictive capability for mortality in our series (AUC) ROC, 0.825 (95% CI 0.752-0.89). Conclusion: In this contemporary CS cohort, the aforementioned scores have been shown to have good predictive ability for hospital mortality. These findings could contribute to a more accurate risk stratification in CS.(AU)

Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP) / Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)

La vía clínica de recuperación intensificada en cirugía cardiaca (RICC) pretende identificar, difundir y favorecer la implementación de las mejores actuaciones basadas en la evidencia científica para disminuir la variabilidad en la práctica clínica. La puesta en marcha de estas prácticas en el proceso clínico global favorecerá la obtención de mejores resultados, acortamiento de estancias hospitalarias y en la Unidad de Cuidados Críticos, lo que permitirá una reducción de costes y una mayor eficiencia. Tras realizar una revisión sistemática en cada uno de los puntos del proceso perioperatorio en cirugía cardiaca, se han redactado recomendaciones basadas en la mejor evidencia científica disponible en la actualidad con el consenso de las sociedades científicas implicadas.(AU)

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.(AU)

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). / Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP).

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

Epidemiología de la leucemia mieloide crónica en España y sus posibles implicaciones terapéuticas / Epidemiology of chronic myeloid leukemia in Spain and its possible therapeutic implications

No disponible

Atypical IgM multiple myeloma with deletion of c-MAF.

IgM multiple myeloma (MM) is a rare subtype of myeloma that shares clinical and pathological features with Waldenström's macroglobulinaemia. These are two separate entities that differ both in therapy and prognosis. We report a 57-year-old male, who presented with anaemia, hypercalcaemia, acute renal failure and several vertebral fractures that clinically suggested a multiple myeloma. Further investigations revealed a serum monoclonal component of IgM lambda type and a bone marrow infiltrated by small, lymphoplasmocytic cells. IgM MM was finally diagnosed by means of both inmunophenotypic and immunohistochemistry techniques, stressing the importance of inmunophenotypic evaluation when clinical and morphological features are discordant. Fluorescence in situ hybridization (FISH) studies disclosed a particular combination of deletion 13q14, t(11;14) and monoallelic deletion C-MAF without t(14;16). The clinical evolution after a Bortezomib-containing polychemotherapy and autologous stem cell transplantation (ASCT) conditioned with busulphan and melphalan is also presented. This very uncommon case highlights the impact of immunophenotyping on the differential diagnosis between IgM MM and WM, to choose the best treatment and establish an appropriate outcome.

[Retrospective comparative study between sevoflurane and propofol in maintaining anaesthesia during liver transplant: Effects on kidney and liver function]. / Estudio retrospectivo comparativo entre sevoflurano y propofol en el mantenimiento de la anestesia durante el trasplante hepático. Efectos sobre la función renal y hepática.

OBJECTIVE: To compare the post-operative effects of sevoflurane versus propofol on liver and kidney function while maintaining anaesthesia in the orthotopic liver transplant (OLT), as well as to analyse the short-term survival as regards these functions. PATIENTS AND METHODS: A retrospective analysis was conducted on patients subjected to an OLT between January 2002 and December 2009. Patients on pre-transplant haemodialysis, re-transplants, and hepatorenal transplants were excluded. The incidence of acute renal failure, initial dysfunction of the graft, reperfusion syndrome, rejection, and the transaminase peak depending value depending on the hypnotic used, were recorded. RESULTS: About one-third (31.2%) of the patients developed acute renal failure and 11.9% an initial dysfunction, with no differences between the groups. There was a tendency for a lower incidence of initial dysfunction of the graft in the sevoflurane group (8.6% compared to 12.8%), a lower transaminase peak (greater than 2000 U/L, 12.1% versus 15.9%), and a lower incidence of reperfusion syndrome (10.3% compared to 21.6%). CONCLUSIONS: Despite the fact that the renal metabolism sevoflurane is elevated, we did not find any higher incidence of acute renal failure. Sevoflurane in the liver transplant anaesthesia is as least equally as safe propofol as regards renal function and liver function. New prospective studies are needed to clarify the possible effects of the hypnotic in liver transplant.

Estudio retrospectivo comparativo entre sevoflurano y propofol en el mantenimiento de la anestesia durante el trasplante hepático. Efectos sobre la función renal y hepática / Retrospective comparative study between sevoflurane and propofol in maintaining anaesthesia during liver transplant: effects on kidney and liver function

Objetivo. Comparar la repercusión postoperatoria sobre la función hepática y renal del sevofluorano frente al propofol durante el mantenimiento de la anestesia en el trasplante hepático ortotópico, así como analizar la supervivencia a corto plazo en relación a dichas funciones. Pacientes y métodos. Análisis retrospectivo de pacientes sometidos a THO entre enero de 2002 y diciembre de 2009. Fueron excluidos los pacientes con hemodiálisis pretrasplante, los retrasplantes y trasplantes hepatorrenales. Se comparó la incidencia de insuficiencia renal aguda, disfunción inicial del injerto, síndrome de reperfusión, rechazo y el pico máximo de transaminasas en función del hipnótico utilizado. Resultados. Un 31,2% de los pacientes desarrolló insuficiencia renal aguda y un 11,9% disfunción inicial, sin diferencias entre los grupos. Hubo tendencia a una menor incidencia de disfunción inicial del injerto en el grupo sevoflurano (8,6 frente a 12,8%), menor pico de transaminasas (más de 2.000 U/L, 12,1 frente a 15,9%) y menor incidencia de síndrome de reperfusión (10,3 frente a 21,6%). Conclusiones. A pesar de que en el trasplante el metabolismo renal del sevofluorano está aumentado, no hemos encontrado mayor incidencia de insuficiencia renal aguda. El sevofluorano en la anestesia del trasplante de hígado es al menos igual de seguro sobre la función renal y la función hepática que el propofol. Son necesarios nuevos trabajos prospectivos para clarificar la posible repercusión del hipnótico en el trasplante de hígado(AU)

Objective. To compare the post-operative effects of sevoflurane versus propofol on liver and kidney function while maintaining anaesthesia in the orthotopic liver transplant (OLT), as well as to analyse the short-term survival as regards these functions. Patients and methods. A retrospective analysis was conducted on patients subjected to an OLT between January 2002 and December 2009. Patients on pre-transplant haemodialysis, re-transplants, and hepatorenal transplants were excluded. The incidence of acute renal failure, initial dysfunction of the graft, reperfusion syndrome, rejection, and the transaminase peak depending value depending on the hypnotic used, were recorded. Results. About one-third (31.2%) of the patients developed acute renal failure and 11.9% an initial dysfunction, with no differences between the groups. There was a tendency for a lower incidence of initial dysfunction of the graft in the sevoflurane group (8.6% compared to 12.8%), a lower transaminase peak (greater than 2000 U/L, 12.1% versus 15.9%), and a lower incidence of reperfusion syndrome (10.3% compared to 21.6%). Conclusions. Despite the fact that the renal metabolism sevoflurane is elevated, we did not find any higher incidence of acute renal failure. Sevoflurane in the liver transplant anaesthesia is as least equally as safe propofol as regards renal function and liver function. New prospective studies are needed to clarify the possible effects of the hypnotic in liver transplant(AU)

Rhodotorula mucilaginosa catheter-related fungaemia in a patient with multiple myeloma.

To date, there have been several case reports of Rhodotorula infection in haematological patients, but none affecting patients with multiple myeloma (MM). We describe a 54-year-old man with MM receiving prophylaxis with fluconazole who was using a subclavian Port-A-Cath and presented two episodes of fungaemia caused by Rhodotorula mucilaginosa. The first episode was resolved with oral itraconazole and neutropenia recovery. During the second episode, caspofungin was administered without success; however, liposomal amphotericin B and catheter withdrawal resolved the fungaemia. As far as we know, this is the first case reported of R. mucilaginosa fungaemia in a patient with MM.

Epidemiology and outcome of Rhodotorula infection in haematological patients.

Rhodotorula spp. are emergent opportunistic pathogens, particularly in haematological patients. However, no systematic review of this infection has been undertaken in this high-risk patient group. The aim of this study was to review all reported cases of Rhodotorula infection to determine the epidemiology and outcome of this infection in this high-risk population. The 29 reported cases were fungaemias. The most common underlying haematological disorder was the presence of acute leukaemia (65.5%). Rhodotorula mucilaginosa was the species found more frequently (79.3%). Most cases (58.6%) had several risk factors (≥ 3) simultaneously. The most common predisposing factors were the presence of central venous catheter (CVC, 100%) and neutropenia (62.1%). A substantial number of patients (81.5%) received antifungal treatment with amphotericin B. The overall mortality was higher (13.8%) than that described in non-haematological patients (5.8% in solid-organ neoplasms and 9% in AIDS or other chronic diseases). Patients with acute leukaemia had a higher mortality rate (15.7%) than patients with non-Hodgkin's lymphoma (0%). Our data suggest that patients with acute leukaemia might be managed as high-risk patients and intensive measures might be taken. In addition, it appears that the subgroup of patients without acute leukaemia have a good outcome and might be managed as low-risk patients with a less intensive approach.

Hemophagocytic syndrome associated with retinoic acid syndrome in acute promyelocytic leukemia.

A 56-year-old woman with an acute promyelocytic leukemia (APL) developed a severe all-trans-retinoic (ATRA) syndrome on day 17 of treatment. Shortly after, she presented a picture of pancytopenia, hepatosplenomegaly, increased triglycerides, ferritin, and liver enzymes. A bone marrow biopsy showed abundant macrophages and no evidence of leukemia. Tests for secondary hemophagocytic syndrome (HPS) were negative. A diagnosis of HPS was made. Treatment with dexamethasone and high-dose immunoglobulins was unsuccessful. Consolidation chemotherapy with idarubicin and ATRA rapidly reversed the HPS. The HPS in this patient could be related to the release of macrophage-stimulating cytokines by APL cells during ATRA syndrome.

Indicaciones del empleo de inmunoglobulinas intravenosas / No disponible

No disponible

Translocation t(4; 6)(q21; q27) in a case of primary thrombocythaemia in transformation.

We report a case of primary thrombocythaemia showing a translocation t(4; 6)(q21; q27) five years after diagnosis. The patient had been treated with hydroxyurea. The clinical picture at the time was consistent with transformation. Karyotypic abnormalities are rare in this disease and are reviewed.

HCV-associated thrombocytopenia: clinical characteristics and platelet response after recombinant alpha2b-interferon therapy.

Hepatitis C virus (HCV) has been proposed as a possible causative agent of chronic thrombocytopenia. We investigated HCV infection in a series of 51 unselected Spanish patients with chronic acquired thrombocytopenia. Anti-HCV and HCV viraemia were detected in 13/51 (22.5%) of cases; this prevalence was particularly significant when compared with HCV seropositivity in age-matched controls (0.4%). Anti-HCV-positive patients, four men and nine women with a median age of 59.3 years (range 36-72), had a mean platelet count of 55.8 x 109/l (range 12-96). Only one of our HCV-positive thrombocytopenic patients had hypersplenism. Platelet-associated IgG (PAIgG) was negative, as measured by immunofluorescent flow cytometric analysis in 11/13 HCV-positive thrombocytopenic patients. Thus, thrombocytopenia in our HCV-positive patients appeared to be non-autoimmune mediated. In six patients, a trial of recombinant alpha2b-interferon (IFN-alpha) given at a dose of 3 MU three times per week for 6-24 months gave a durable (> 1 year) and significant increase in platelet count in all six patients. The maximum increase occurred after 6 months of IFN-alpha therapy. In conclusion, the ability of IFN-alpha to increase platelet counts in HCV-positive thrombocytopenic patients supports mechanisms involving a direct role for HCV inhibiting platelet production.

Myelodysplastic syndrome with erythroid hypoplasia/aplasia: a case report and review of the literature.

Myelodysplastic syndrome (MDS) with erythroid hypoplasia/aplasia has not yet been clearly defined, and in most patients it is mistaken for acquired pure red cell aplasia (PRCA). We report a patient with severe transfusion-dependent anemia (Hb 6.9 g/dl) and reticulocytopenia. WBC and platelet counts were normal. Bone marrow examination showed a marked trilineage dysplasia and a low percentage of erythroid precursors (3%). A diagnosis of MDS (refractory anemia according to FAB classification) with erythroid hypoplasia/aplasia was made. Repeated cytogenetic analysis of bone marrow showed normal karyotypes. Moreover, serial IgM serology and DNA analysis of the patient's sera for B19 parvovirus were negative. Other conditions known to be associated with erythroid aplasia were also absent. The patient failed hematinics and prednisone therapy. He next received r-HuEPO (200 U/kg three times weekly). This form of therapy achieved a rapid and complete erythroid response. He has remained in complete erythroid response after a 7-month period on maintenance therapy of 100 U/kg three times weekly. A review of the literature revealed only 15 well-documented cases of MDS with erythroid hypoplasia/aplasia. All had morphological evidence of myelodysplasia. These patients were predominantly elderly males, all required regular packed red cell transfusions, and had an unfavorable prognosis, mainly because of a high rate of blastic transformation (frequently preceded by a myeloproliferative phase). The mechanism of erythroid hypoplasia in this subgroup of MDS remains uncertain. However, laboratory and clinical data suggest the existence of an intrinsic stem cell defect. None of the patients received hematopoietic growth factors. To our knowledge, our patient is the first case of MDS with erythroid hypoplasia where r-HuEPO was successfully attempted. The description of more cases is necessary to delineate the value of r-HuEPO therapy in this rare variant of MDS.

Altered pattern of cytokine production by peripheral blood CD2+ cells from B chronic lymphocytic leukemia patients.

To determine if activation-induced cytokine production is altered in CD2+ lymphocytes from B-CLL patients, cytokine levels were determined by ELISA in supernatants of PHA-stimulated cultures of CD2+ cells from 33 B-CLL patients and 22 healthy controls. The production of Interferon gamma (IFN-gamma) and Tumor Necrosis Factor (TNF-alpha) by mitogen-activated CD2+ lymphocytes from B-CLL patients was higher than that found in healthy controls, while no differences were found in TNF-beta production. IFN-gamma and TNF-alpha levels determined at 72 h in PHA-stimulated CD2+ cell cultures from B-CLL patients statistically correlated with the percentages of CD3+CD45RO+ and CD3-CD56+ lymphocytes, respectively. Although there were differences in the production kinetics of interleukins (ILs) 2 and 4 between B-CLL patients and the healthy controls, no differences were found at the time when the levels of both interleukins peak. The production of both IFN-gamma and IL-4 by PHA-stimulated CD2+ lymphocytes from non-smouldering B-CLL patients was significantly higher than that from smouldering B-CLL patients while no significant differences were found in the production of IL-2, TNF-alpha, and TNF-beta between the two B-CLL patient groups. These data suggest that functional alterations in the production of cytokines by CD2+ cells from B-CLL patients could help to explain the expansion of leukemic cells in B-CLL patients.