Structural differences in the diaphragm of patients following controlled vs assisted and spontaneous mechanical ventilation.

PURPOSE: Ventilator-induced diaphragm dysfunction or damage (VIDD) is highly prevalent in patients under mechanical ventilation (MV), but its analysis is limited by the difficulty of obtaining histological samples. In this study we compared diaphragm histological characteristics in Maastricht III (MSIII) and brain-dead (BD) organ donors and in control subjects undergoing thoracic surgery (CTL) after a period of either controlled or spontaneous MV (CMV or SMV). METHODS: In this prospective study, biopsies were obtained from diaphragm and quadriceps. Demographic variables, comorbidities, severity on admission, treatment, and ventilatory variables were evaluated. Immunohistochemical analysis (fiber size and type percentages) and quantification of abnormal fibers (a surrogate of muscle damage) were performed. RESULTS: Muscle samples were obtained from 35 patients. MSIII (n = 16) had more hours on MV (either CMV or SMV) than BD (n = 14) and also spent more hours and a greater percentage of time with diaphragm stimuli (time in assisted and spontaneous modalities). Cross-sectional area (CSA) was significantly reduced in the diaphragm and quadriceps in both groups in comparison with CTL (n = 5). Quadriceps CSA was significantly decreased in MSIII compared to BD but there were no differences in the diaphragm CSA between the two groups. Those MSIII who spent 100 h or more without diaphragm stimuli presented reduced diaphragm CSA without changes in their quadriceps CSA. The proportion of internal nuclei in MSIII diaphragms tended to be higher than in BD diaphragms, and their proportion of lipofuscin deposits tended to be lower, though there were no differences in the quadriceps fiber evaluation. CONCLUSIONS: This study provides the first evidence in humans regarding the effects of different modes of MV (controlled, assisted, and spontaneous) on diaphragm myofiber damage, and shows that diaphragm inactivity during mechanical ventilation is associated with the development of VIDD.

Severe vitamin D deficiency upon admission in critically ill patients is related to acute kidney injury and a poor prognosis. / La hipovitaminosis D grave al ingreso en el paciente crítico se asocia a fracaso renal agudo y mal pronóstico.

OBJECTIVES: To evaluate the prevalence of vitamin D deficiency in critically ill patients upon admission to an Intensive Care Unit (ICU) and its prognostic implications. DESIGN: A single-center, prospective observational study was carried out from January to November 2015. Patients were followed-up on until death or hospital discharge. SETTING: The department of Critical Care Medicine of a university hospital. PATIENTS: All adults admitted to the ICU during the study period, without known factors capable of altering serum 25(OH)D concentration. INTERVENTIONS: Determination of serum 25(OH)D levels within the first 24h following admission to the ICU. MAIN VARIABLES OF INTEREST: Prevalence and mortality at 28 days. RESULTS: The study included 135 patients, of which 74% presented deficient serum 25(OH)D levels upon admission to the ICU. Non-survivors showed significantly lower levels than survivors (8.14ng/ml [6.17-11.53] vs. 12ng/ml [7.1-20.30]; P=.04], and the serum 25(OH)D levels were independently associated to mortality (OR 2.86; 95% CI 1.05-7.86; P=.04]. The area under the ROC curve was 0.61 (95% CI 0.51-0.75), and the best cut-off point for predicting mortality was 10.9ng/ml. Patients with serum 25(OH)D<10.9ng/ml also showed higher acute kidney injury rates (13 vs. 29%; P=.02). CONCLUSION: Vitamin D deficiency is highly prevalent upon admission to the ICU. Severe Vitamin D deficiency (25[OH]D<10.9ng/ml) upon admission to the ICU is associated to acute kidney injury and mortality.

Characteristics and outcomes of patients admitted to Spanish ICU: A prospective observational study from the ENVIN-HELICS registry (2006-2011).

OBJECTIVE: To describe the case-mix of patients admitted to intensive care units (ICUs) in Spain during the period 2006-2011 and to assess changes in ICU mortality according to severity level. DESIGN: Secondary analysis of data obtained from the ENVN-HELICS registry. Observational prospective study. SETTING: Spanish ICU. PATIENTS: Patients admitted for over 24h. INTERVENTIONS: None. VARIABLES: Data for each of the participating hospitals and ICUs were recorded, as well as data that allowed to knowing the case-mix and the individual outcome of each patient. The study period was divided into two intervals, from 2006 to 2008 (period 1) and from 2009 to 2011 (period 2). Multilevel and multivariate models were used for the analysis of mortality and were performed in each stratum of severity level. RESULTS: The study population included 142,859 patients admitted to 188 adult ICUs. There was an increase in the mean age of the patients and in the percentage of patients >79 years (11.2% vs. 12.7%, P<0.001). Also, the mean APACHE II score increased from 14.35±8.29 to 14.72±8.43 (P<0.001). The crude overall intra-UCI mortality remained unchanged (11.4%) but adjusted mortality rate in patients with APACHE II score between 11 and 25 decreased modestly in recent years (12.3% vs. 11.6%, odds ratio=0.931, 95% CI 0.883-0.982; P=0.008). CONCLUSION: This study provides observational longitudinal data on case-mix of patients admitted to Spanish ICUs. A slight reduction in ICU mortality rate was observed among patients with intermediate severity level.

[Comparative analysis of patients admitted to Spanish Intensive Care Units due to medical and surgical disease]. / Análisis comparativo de pacientes ingresados en Unidades de Cuidados Intensivos españolas por causa médica y quirúrgica.

OBJECTIVE: To describe the characteristics of the patients case-mix admitted to ICUs due to medical and surgical disease, and to compare both groups. DESIGN: Analysis of data covering the period 2006-2011 in the ENVIN-HELICS registry. An observational, prospective, multicenter and voluntary participation study. SETTING: A total of 188 Spanish ICUs. PATIENTS: All patients admitted for more than 24 hours. MAIN VARIABLES: Demographic data, cause of admission, severity scores, length of stay, mortality. RESULTS: A total of 138,999 patients were analyzed. Of these, 65,467 (47.1%) were admitted due to a non-coronary medical cause, 27,785 (20,0%) due to coronary-related illness, 28,044 (20,2%) after elective surgery and 17,613 (12.7%) after urgent surgery. Use of devices, nosocomial infections and isolation of multirresistant organisms were more prevalent in urgent surgery patients. Longer length of stay (median 5 days; interquartile range 2-11) as well as higher severity scale values (APACHE II and SAPS II) corresponded to this same group of patients. Mortality was higher in non-coronay medical patients. On categorizing the patients according to the APACHE II score, mortality was seen to be higher in urgent surgery cases than in elective surgery patients in all groups. The largest difference was observed in the APACHE II score 6-10 group (3% vs. 0.9%) (OR: 2.14, 95% CI 1.825-2.513; p<0.001). CONCLUSIONS: The mortality rate is higher in non-coronary medical patients, though resource use per patient is greater in the urgent surgery cases. The APACHE II scale underestimates mortality in emergency surgery patients.

Monitorización del flujo sanguíneo regional cerebral mediante la flujometría por difusión termal. Descripción de 3 casos / No disponible

El flujo sanguíneo cerebral es el parámetro más importante en el pronóstico de la lesión cerebral. Una medida regional del flujo se puede obtener usando métodos continuos como la flujometría por difusión termal, que permite detectar y cuantificar fenómenos isquémicos relacionados con el clipaje temporal arterial o malposición del clip definitivo y en pacientes que han sufrido una hemorragia subaracnoidea o un traumatismo craneoencefálico. Asimismo, la detección precoz de la isquemia podría ayudarnos a adoptar más rápidamente medidas terapéuticas y con mayor eficacia. Presentamos 2 casos durante cirugía de clipaje de aneurisma y un caso en cuidados intensivos donde valoramos: el efecto de diferentes hipnóticos sobre la flujometría por difusión termal; la relación entre esta y los potenciales evocados somatosensoriales y motores; y cambios en la flujomería y Doppler transcraneal durante el vasoespasmo. La flujometría por difusión termal mostró variaciones en tiempo real del flujo sanguíneo producidas por anestésicos endovenosos e inhalatorios. Detectó cambios del flujo sanguíneo cerebral antes que los potenciales evocados y el Doppler(AU)

No disponible

[Regional cerebral blood flow monitoring using thermal diffusion flowmetry. Description of 3 cases]. / Monitorización del flujo sanguíneo regional cerebral mediante la flujometría por difusión termal. Descripción de 3 casos.

Cerebral blood flow is the most important physiologic parameter in the setting of brain injury. A regional measurement of the flow (rCBF), can be obtained using continuous methods such as thermal diffusion flowmetry (TD-rCBF). This technology of monitoring allows us to detect and quantify ischemic events related with the temporary artery clipping or malposition of the definitive clip and in patients who have suffered a subarachnoid hemorrhage (SAH) or a traumatic brain injury. Likewise, the precocious detection of ischemic events might help us to adopt more rapidly therapeutic measures and more efficienty. Three cases show during aneurysm clipping procedures and at intensive care: the effects of different hypnotics on TD-rCBF values; the relationship between TD-rCBF and somatosensory and motor evoked potentials; and changes in TD-rCBF and transcranial Doppler ultrasonography (TDU) during a vasospasm. TD-rCBF showed in real-time flow variations induced by anaesthetics and detected changes of CBF earlier than evoked potentials and TDU.

Resistance to powdery mildew in Spanish barley landraces is controlled by different sets of quantitative trait loci.

Twenty-two landrace-derived inbred lines from the Spanish Barley Core Collection (SBCC) were found to display high levels of resistance to a panel of 27 isolates of the fungus Blumeria graminis that exhibit a wide variety of virulences. Among these lines, SBCC145 showed high overall resistance and a distinctive spectrum of resistance compared with the other lines. Against this background, the main goal of the present work was to investigate the genetic basis underlying such resistance using a doubled haploid population derived from a cross between SBCC145 and the elite spring cultivar Beatrix. The population was genotyped with the 1,536-SNP Illumina GoldenGate Oligonucleotide Pool Assay (Barley OPA-1 or BOPA1 for short), whereas phenotypic analysis was performed using two B. graminis isolates. A major quantitative trait locus (QTL) for resistance to both isolates was identified on the long arm of chromosome 6H (6HL) and accounted for ca. 60% of the phenotypic variance. Depending on the B. graminis isolate tested, three other minor QTLs were detected on chromosomes 2H and 7H, which explained less than 5% of the phenotypic variation each. In all cases, the alleles for resistance derived from the Spanish parent SBCC145. The position, the magnitude of the effect observed and the proportion of phenotypic variation accounted for by the QTL on 6HL suggest this is a newly identified locus for broad-based resistance to powdery mildew.

[False images of endobronchial tumor in CT-scan]. / Falsas imágenes de tumoración endobronquial por tomografía computarizada.

Bronchoscopic identification of an endobronchial foreign body is an unexpected finding in adults. Modern imaging techniques such as computerised tomography (CT) may identify bronchial obstruction but not the cause. Moreover, images may be suggestive of other pathologies, especially when the previous aspiration cases are unknown. The most common CT findings in this setting are atelectasis, lung hyperlucency, localised bronchiectases and lobar consolidation. CT diagnosis of false endobronchial tumors in patients who have swallowed a foreign body is rarely described in the bibliography. In view of the potential adverse outcome in the case of wrong diagnosis we consider it is of interest to report two cases of endobronchial tumors diagnosed by CT in which flexible bronchoscopy allowed identification and extraction of an endobronchial foreign body.

Falsas imágenes de tumoración endobronquial por tomografía computarizada / False images of endobronchial tumor in CT-scan

La identificación mediante broncoscopia de uncuerpo extraño endobronquial es a menudo unhallazgo no esperado entre los adultos. Enocasiones, las más modernas técnicas de imagen,como la tomografía computarizada (TC), aunquepueden identificar la ocupación bronquial, nopermiten reconocer su naturaleza e incluso puedensimular otro tipo de patologías, sobre todo cuandose desconoce el antecedente de aspiración. Loshallazgos más habituales en la TC suelen ser lasatelectasias, la hiperclaridad pulmonar, lasbronquiectasias localizadas y la consolidación lobar.El falso diagnóstico de tumoración endobronquialpor TC, en sujetos que han sufrido la aspiración deun cuerpo extraño, se halla muy poco referido en laliteratura. Dadas las repercusiones pronósticas quepuede acarrear un diagnóstico incorrecto nos parecede interés reportar dos casos diagnosticados porTC de tumoración endobronquial y en los que lafibrobroncoscopia permitió la identificación y laextracción del cuerpo extraño endobronquial

Bronchoscopic identification of an endobronchialforeign body is an unexpected finding in adults.Modern imaging techniques such as computerisedtomography (CT) may identify bronchial obstructionbut not the cause. Moreover, images may besuggestive of other pathologies, especially when theprevious aspiration cases are unknown. The mostcommon CT findings in this setting are atelectasis,lung hyperlucency, localised bronchiectases andlobar consolidation. CT diagnosis of falseendobronchial tumors in patients who haveswallowed a foreign body is rarely described in thebibliography. In view of the potential adverseoutcome in the case of wrong diagnosis we considerit is of interest to report two cases of endobronchialtumors diagnosed by CT in which flexiblebronchoscopy allowed identification and extractionof an endobronchial foreign body

[Usefulness of activated recombinant factor VII for controlling massive bleeding: 4 years' experience in a university hospital]. / Utilidad del factor VII recombinante para el control de la hemorragia masiva. Experiencia de cuatro años en un centro hospitalario universitario.

OBJECTIVE: Massive bleeding that cannot be controlled by the usual means, such as transfusion, is a serious medical problem with high associated mortality. Our aim was to assess the efficacy and safety of treatment with activated recombinant factor VII (rFVIIa) to control massive bleeding after the failure of other methods. PATIENTS AND METHODS: This was a retrospective study of all cases of rFVIIa-treated massive bleeding in patients without a history of coagulation disorder from January 2003 through June 2007. RESULTS: The prevalence of rFVIIa treatment for this indication was 1 in 5200 hospitalized patients. Thirty patients were treated. Bleeding was reduced or stopped in 80% and consumption of blood products was reduced after administration of rFVIIa. Mortality was 43% and death was due to continued bleeding in 5 cases. No deaths were due to thromboembolism. CONCLUSIONS: rFVIIa is efficacious for controlling bleeding and reducing transfusion requirements in cases of massive hemorrhage, but mortality unrelated to bleeding is high in patients experiencing this complication. Further study is needed to better assess the utility, dosing, and ideal timing in the use of this drug.

Utilidad del factor VII recombinante para el controlde la hemorragia masiva. Experiencia de cuatro añosen un centro hospitalario universitario / No disponible

OBJETIVO: La hemorragia masiva no controlada pese alas medidas terapéuticas habituales como el soporte transfusional,supone un grave problema médico y tiene unaelevada mortalidad. El objetivo del trabajo ha sido evaluarla eficacia y seguridad del tratamiento con factor VII activadorecombinante (rFVIIa) en el control de la hemorragiamasiva, cuando las demás medidas han fracasado.PACIENTES Y MÉTODOS: Estudio retrospectivo de todoslos casos de hemorragia masiva en pacientes sin transtornoprevio de la coagulación, que fueron tratados conrFVIIa en nuestro centro desde enero de 2003 a junio de2007.RESULTADOS: La prevalencia de uso de rFVIIa con estaindicación ha sido de 1/5.200 pacientes hospitalizados. Sehan tratado 30 pacientes de los cuales el sangrado se redujoo paró en el 80% de los casos, con una disminución deluso de hemoderivados tras la administración de rFVIIa.La mortalidad fue del 43%, 5 casos por persistencia delsangrado, pero ninguna muerte fue por proceso tromboembólico.CONCLUSIONES: El rFVIIa resulta eficaz en el control delsangrado y en reducir los requerimientos transfusionalesen la hemorragia masiva, pero la mortalidad en estospacientes por causa no hemorrágica es alta. Son necesariosmás estudios para evaluar mejor la utilidad, dosificación ymomento idóneo de administración de este fármaco (AU)

OBJECTIVE: Massive bleeding that cannot be controlledby the usual means, such as transfusion, is a seriousmedical problem with high associated mortality. Our aimwas to assess the efficacy and safety of treatment withactivated recombinant factor VII (rFVIIa) to controlmassive bleeding after the failure of other methods.PATIENTS AND METHODS: This was a retrospective studyof all cases of rFVIIa-treated massive bleeding in patientswithout a history of coagulation disorder from January2003 through June 2007.RESULTS: The prevalence of rFVIIa treatment for thisindication was 1 in 5200 hospitalized patients. Thirtypatients were treated. Bleeding was reduced or stopped in80% and consumption of blood products was reducedafter administration of rFVIIa. Mortality was 43% anddeath was due to continued bleeding in 5 cases. No deathswere due to thromboembolism.CONCLUSIONS: rFVIIa is efficacious for controllingbleeding and reducing transfusion requirements in cases ofmassive hemorrhage, but mortality unrelated to bleedingis high in patients experiencing this complication. Furtherstudy is needed to better assess the utility, dosing, and idealtiming in the use of this drug (AU)

Patterns of genetic and eco-geographical diversity in Spanish barleys.

The pool of Western Mediterranean landraces has been under-utilised for barley breeding so far. The objectives of this study were to assess genetic diversity in a core collection of inbred lines derived from Spanish barley landraces to establish its relationship to barleys from other origins, and to correlate the distribution of diversity with geographical and climatic factors. To this end, 64 SSR were used to evaluate the polymorphism among 225 barley (Hordeum vulgare ssp. vulgare) genotypes, comprising two-row and six-row types. These included 159 landraces from the Spanish barley core collection (SBCC) plus 66 cultivars, mainly from European countries, as a reference set. Out of the 669 alleles generated, a large proportion of them were unique to the six-row Spanish barleys. An analysis of molecular variance revealed a clear genetic divergence between the six-row Spanish barleys and the reference cultivars, whereas this was not evident for the two-row barleys. A model-based clustering analysis identified an underlying population structure, consisting of four main populations for the whole genotype set, and suggested further possible subdivision within two of these populations. Most of the six-row Spanish landraces clustered into two groups that corresponded to geographic regions with contrasting environmental conditions. The existence of wide genetic diversity in Spanish germplasm, possibly related to adaptation to a broad range of environmental conditions, and its divergence from current European cultivars confirm its potential as a new resource for barley breeders, and make the SBCC a valuable tool for the study of adaptation in barley.

[Allocation of resources in patients with bad prognosis: the need for debate]. / La adjudicación de recursos en los pacientes con mal pronóstico: la necesidad de un debate.

OBJECTIVE: Assess the opinion of health care professions on the awarding of resources when the patient has a bad prognosis. DESIGN: Survey type test where a scenario of a patient with a 6 month life prognosis is posed, differentiating between good and bad quality of life. It is evaluated if the following resources would be indicated if necessary: admission to ICU, hemodialysis, hip prosthesis, transplant, Hospital admission, antibiotics for bacterial infection, permanent pacemaker and surgery. To analyze the possible association between the variables, the Pearson's Chi Square Test or that of linear tendency was used. To determine if each person interviewed was appropriate in a different way based on the patient's quality of life status, the McNemar test was used. SETTING: University Hospital of 480 beds. PARTICIPANTS: Sample of 256 volunteers (physicians and nurses) from the Emergency Service, Intensive Care Unit and Operating Room. INTERVENTIONS: A responsible physician was in charge of personally distributing the survey during a 2-week period and to explain the possible doubts that could arise on it. RESULTS: A total of 23.8% of those surveyed considered that transplant would be indicated and 79.8% that permanent pacemaker would be indicated if the patient had a good quality of life. If there was bad quality of life, 9.1% would have always indicated hemodialysis (60.5% never), 2.8% hip prosthesis (81.1% never) and 4% complex surgery (78.8% never). There were also significant differences in all the variables studied, depending on whether the patient had good or bad quality of life. CONCLUSION: There is great variability on the allotment of resources for patients with limited possibilities of survival.

Morphological and agronomical diversity patterns in the Spanish barley core collection.

Seven thousand years of barley cultivation under the environmental hardships typical of the Mediterranean climate have generated genetic singularity of the Spanish barleys, consistently reported in the literature. From the Spanish National Collection of 2289 accessions, a core subset with 159 landraces and 16 old varieties was constituted. Twenty-seven characters were evaluated for the core collection, to define the structure of the diversity. Several evaluation trials were carried out in 1999-2000, whereas yield trials were performed in earlier years. Phenotypic diversity was large for most of the characters studied. Comparisons of genetic diversity between the core and the original collections suggested that the core is a good representation of the existing diversity in the BNG. Comparisons with results of studies on Spanish materials from other collections seem to indicate that the Spanish diversity is not well represented in some world collections. Principal component analyses for quantitative and qualitative characters revealed a clear distinction between two- and six-row cultivars, and also between landraces and commercial varieties. Geographical origins of the landraces were correlated with grain yield, heading date, duration of grain filling period, and growth class. In relation to diseases, altitude played an important role on the resistance to powdery mildew and brown rust. For brown rust, all the resistant landraces came from low altitudes. These geographical gradients seemed consistent with prior knowledge about barley adaptation, and would confirm the agreement between passport data and true adaptive origin of these landraces from a geographical point of view.

Tetramicra brevifilum (Matthews & Matthews, 1980) (Microsporida: Tetramicriidae) in a new fish host, Lophius budegassa (Spinola, 1807) in Spain.

Tetramicra brevifilum, a microsporidian parasite of Scophthalmus maximus, was found in Lophius budegassa for the first time. This parasite was detected in 5 of 199 hosts captured in the coastal waters of Barcelona (Northwest Mediterranean), which enlarges the geographic distribution of this microsporidian. Affected fish did not show any external sign of disease, and cysts of T. brevifilum were found associated with the body musculature but were easily differentiated from those of Spraguea lophii, another microsporidian present in this host. A case of simultaneous infection by both T. brevifilum and S. lophii was found.

The pathologic cycle of the infection of the microsporidian Microgemma ovoidea (Thèl., 1895) Amigó et al. 1996 in the liver of the Red Band fish (Cepola macrophthalma L.).

Pathologic study of the lesions caused by Microgemma ovoidea has shown that after the formation of the xenoma (stage 1), the parasitized cell is infiltrated by host macrophages (stage 2) and quickly encysted by the activity of fibroblasts that form a xenoma wall composed of collagenous fibers (stage 3). The phagocytic activity of the macrophages leads to the formation of a granuloma (stage 4) in which the cyst contents comprise macrophages filled with phagocytosed spores. This phagocytic activity is limited by the fact that some parts of the microsporidian spores, such as the spore walls, cannot be lysed by macrophages, which leads to the formation of fused giant cells containing nondigestible spore remanants. The final step in the process is healing (stage 5), in which some cells may start proliferating to regenerate the damaged area. Nevertheless, the host occasionally fails to control M. ovoidea infections. This failure can take two forms: bursting of the granuloma, or the appearance of secondary infections in granulomas, probably through parasitism of macrophages.

[Delay time to arrive at the hospital of 275 patients with acute myocardial infarction. Study form the province of Teruel (1991-1994)]. / Tiempo de demora en acudir al hospital de 275 pacientes con infarto agudo de miocardio. Análisis de la provincia de Teruel (1991-1994).

BACKGROUND: To study the delay time to arrive of the hospital and its relation with any variables, of patients with acute myocardial infarction from the province of Teruel (Spain). PATIENTS AND METHODS: A prospective study was carried out from January 1991 to October 1994. We included patients who were diagnosticated of the acute myocardial infarction (212 men and 63 women). We considered the time between the thoracic pain and their arrive at the urgency service. We based the diagnosis in clinical, electrocardiographic and enzymatic criteria. RESULTS: The mean delay time was 8 h 46 m. The 66.5% arrives before 6 hours. We found no differences between rural or urban patients. The delay time was minor in men than women (7 h 12 m versus 14 h, p = 0.0019), in younger (< 65 years old) than in the older (6 h 3 m versus 10 h 18 m, p = 0.0278), and in those who were admitted to the ICU (7h 16 m versus 20 h 33 m, p = 0.0001). Was longer in patients with arterial hypertension and diabetes. Was minor in patients with dyslipemia and tobacco habit. Many patients to arrive of the hospital by physician order and with own vehicles, it took less time arrive at the hospital than by ambulance (8 h 30 m versus 18 h, p < 0.05). The medium delay in the emergency area was 2 h 35 m. The delay time was longer in patients who died (16 h versus 7h 30 m, p = 0.0018) and in those who present more frequently cardiac failure. CONCLUSIONS: The mean delay time to arrive at the hospital in patients with acute myocardial infarction from the province of Teruel (Spain) in unreasonable and in takes a poor prognosis, so we consider necessary to study the causes of this delay in order to correct them.