Predictors of first hospitalization due to disease activity and infections in systemic lupus erythematosus patients.

OBJECTIVES: To identify the predictive factors of first hospitalization and associated variables to the main causes of hospitalizations in lupus patients from a Latin American cohort. METHODS: The first hospitalization after entry into the cohort during these patients' follow-up due to either lupus disease activity and/or infection was examined. Clinical and therapeutic variables were those occurring prior to the first hospitalization. Descriptive statistical tests, multivariable logistic, and Cox regression models were performed. RESULTS: 1341 individuals were included in this analysis; 1200 (89.5%) were women. Their median and interquartile range (IQR) age at diagnosis were 27 (20-37) years and their median and IQR follow up time were 27.5 (4.7-62.2) months. A total of 456 (34.0%) patients were hospitalized; 344 (75.4%), 85 (18.6%) and 27 (5.9%) for disease activity, infections, or both, respectively. The predictors of the first hospitalization regardless of its cause were: medium (HR 2.03(1.27-3.24); p = 0.0028) and low (HR 2.42(1.55-3.79); p < 0.0001) socioeconomic status, serosal (HR 1.32(1.07-1.62); p = 0.0074) and renal (HR 1.50(1.23-1.82); p < 0.0001) involvement. Antimalarial (AM) use (HR 0.61(0.50-0.74); p < 0.0001) and achieving remission (HR 0.80(0.65-0.97); p = 0.0300) were negative predictors. CONCLUSIONS: The first hospitalization was associated with worse socioeconomic status and serosal and renal involvement. Conversely, AM use and achieving remission were associated with a lower risk of hospitalizations.

Predictors of severe hemolytic anemia and its impact on major outcomes in systemic lupus erythematosus: Data from a multiethnic Latin American cohort.

OBJECTIVE: To determine the predictors of the occurrence of severe autoimmune hemolytic anemia (AIHA) and its impact on damage accrual and mortality in SLE patients. METHODS: Factors associated with time to severe AIHA (hemoglobin level ≤7 g/dL) occurring from the onset of SLE symptoms were examined by Cox proportional hazards regressions. The association of severe AIHA with mortality was examined by logistic regression analyses while its impact on damage was by negative binomial regression. RESULTS: Of 1,349 patients, 49 (3.6%) developed severe AIHA over a mean (SD) follow-up time of 5.4 (3.8) years. The median time from the first clinical manifestation to severe AIHA was 111 days (IQR 43-450). By multivariable analysis, male sex (HR 2.26, 95% CI 1.02-4.75, p = 0.044), and higher disease activity at diagnosis (HR 1.04, 95% CI 1.01-1.08, p = 0.025) were associated with a shorter time to severe AIHA occurrence. Of the SLEDAI descriptors, only hematologic (leukopenia and/or thrombocytopenia) showed a certain trend toward significance in the multivariable analysis (HR 2.36, 95% CI 0.91-6.13, p = 0.0772). Severe AIHA contributed neither to damage nor to mortality. CONCLUSIONS: Severe AIHA occurs during the early course of SLE. Male sex and higher disease activity at diagnosis emerged as independent predictors of a shorter time to severe AIHA occurrence. Although not statistically significant, hematological abnormalities at SLE diagnosis could predict the occurrence of severe AIHA in a shorter time. Damage and mortality did not seem to be impacted by the occurrence of severe AIHA.

Comparación de máscaras laríngeas (I-gel Fastrach) para realización de intubación endotraqueal guiada con broncofibroscopio flexible / Comparison of I-gel Fastrach laryngeal masks in conducting flexible bronchofiberscope-guided

GOALS: Determine the success rate of guided intubation with a flexible bronchofibroscope (BFC) through supraglottic devices: I-gel or Fastrach, establish the degree of fibroscopic visualization and determine the insertion time of the laryngeal mask airway (LMA) and endotracheal intubation. METHODS: Experimental, prospective, comparative and randomized study of 60 ASA I-II-III patients, older than 18 years, undergoing elective surgeries that required general anesthesia and endotracheal intubation. After anesthetic induction, the assigned LMA was placed and intubation with BFC was performed through it. Both the success of laryngeal mask insertion and intubation were recorded, as well as the time (in seconds) equired for these procedures. The vision of the laryngeal structures was classified according to the Brimacombe Scale. RESULTS: The groups analyzed presented similar general characteristics. Insertion time of he LMA was significantly lower with I-gel than Fastrach (median 12 s vs 16 s. Respectively, p = 0.001). Also, in the intubation time BFC guided through the laryngeal mask, differences in favor of I-gel were found, with a median of 72 s. vs 89 s. (p = 0.001). Regarding the degree of glottic visualization with BFC, no statistically significant differences were found between both groups.CONCLUSIONS: Although both devices had the highest success rate (both in their placement and in intubation through them), with I-gel the intubation was performed quicker.

OBJETIVOS: Determinar la tasa de éxito de intubación guiada con broncofibroscopio flexible (BFC) a través de los dispositivos supraglóticos: I-gel o Fastrach, establecer el grado de visualización fibroscópica y determinar el tiempo de inserción de la máscara laríngea y de intubación endotraqueal. MATERIALES Y MÉTODOS: Estudio experimental, prospectivo, comparativo y aleatorizado de 60 pacientes ASA I- II ­III, mayores de 18 años, sometidos a cirugías electivas que requerían anestesia general e intubación endotraqueal. Luego de la inducción anestésica, se procedió a colocar la máscara laríngea asignada y se realizó la intubación con BFC a través de la misma. Tanto el éxito de inserción de máscara laríngea como de intubación fueron registrados, así como el tiempo (en segundos) requerido para dichos procedimientos. La visión de las estructuras laríngeas fue clasificada de acuerdo a Escala de Brimacombe. RESULTADOS: Los grupos analizados presentaron características generales similares. El tiempo de inserción de la ML fue significativamente menor con I-gel que con Fastrach (medianas: 12 s. vs 16 s. respectivamente, p = 0,001). También en el tiempo de intubación guiada con BFC a través de la máscara laríngea, se encontraron diferencias en favor de I-gel, con una mediana de 72 s. vs 89 s. (p = 0,001). Respecto al grado de visualización glótica con BFC, no se encontraron diferencias estadísticamente significativas entre ambos grupos. CONCLUSIONES: Aunque ambos dispositivos tuvieron la máxima tasa de éxito (tanto en su colocación como en la intubación a través de ellos), con I-gel se realizó la intubación de manera más rápida.

Applying the 2019 EULAR/ACR lupus criteria to patients from an established cohort: a Latin American perspective.

OBJECTIVE: To evaluate the performance of the 2019 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) systemic lupus erythematosus (SLE) criteria in terms of earlier patients' classification in comparison to the 1982/1997 ACR or the 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria. MATERIALS AND METHODS: Patients from a Latin America, multiethnic, multicentre cohort, where SLE was defined using the physicians' diagnosis, were included. To calculate the sensitivity of the 2019 EULAR/ACR criteria, the 1982/1997 ACR criteria were considered the gold standard. Additionally, comparison of the 1982/1997 ACR criteria and the 2012 SLICC criteria with the 2019 EULAR/ACR criteria was performed. RESULTS: The sensitivity of the 2019 EULAR/ACR criteria when compared with the 1982/1997 ACR criteria as the gold standard was 91.3%. This new set of criteria allowed an earlier SLE patient classification in 7.4% (mean 0.67 years) and 0.6% (mean 1.47 years) than the 1982/1997 ACR and the 2012 SLICC criteria, respectively. Patients accruing the 2019 EULAR/ACR earlier than the 1982/1997 ACR criteria were more likely to have high anti-dsDNA titres; those accruing them later were less likely to have mucocutaneous and joint manifestations; this was not observed when comparing them with the 2012 SLICC criteria. CONCLUSIONS: The 2019 EULAR/ACR criteria classified earlier only a small proportion of Latin America patients than with the two other criteria sets in real-life clinical practice scenarios. Further studies in different patient populations are needed before these new criteria are adopted worldwide.

Comparación midazolam vs dexmedetomidina en pacientes con síndrome de apnea obstructiva del sueño / Comparative effects of midazolam dexmedetomidina in patients with obstructive sleep apnea

OBJECTIVE: To compare the efficacy and safety of sedation with midazolam vs dexmedetomidine in patients with high probability of obstructive sleep apnea, to assess hemodynamic parameters, ventilation and depth of hypnosis. METHODS: Patients scheduled to regional anesthesia and sedation participated in this randomly and double-blinded study. The MDZ Group (n = 29) midazolam 0.05 m g ∙ k g ­ 1 ; while the DEX Group (n = 29) dexmedetomidina 0.4 µ g ∙ k g ­ 1 ∙ h ­ 1 . Systolic and Diastolic Blood Presion (SBP and DBP), Heart Rate (HR), Respiratory Rate (RR) peripheral oxygen saturations (SpO2), and bispectral index (BIS) scores were recorded during surgery. RESULTS: Patient demographics were similar in the two groups. There were no differences with respect to SBP and DBP. The DEX group decreased significantly HR 10' (p = 0.001), 15' (p = 0.002), 20' (p = 0.004); the MDZ group decreased significantly RR (p < 0.0001), 10' (p < 0.0001), 15' (p = 0.001), 30' (p = 0.001), 45' (p = 0.0019), 60' (p = 0.001), and SAT O2 5' (p = 0.032), 10' (p = 0.033), 15' (p = 0.059), 30' (p = 0.033), 45' (p = 0.047), 60' (p = 0.028) compare to DEX group. The MDZ group decreased significantly BIS 5' (p < 0.0001), 10' (p < 0.0001), 15' (p = 0.001), 30' (p < 0.001), 45' (p = 0.003), 60' (p = 0.038), compare to DEX group. CONCLUSION: The use of DEX for sedation in patients with high probability of obstructive sleep apnea provides better control over the depth of sedation, to compare with MDZ.

OBJETIVO: Comparar efecto de sedación, midazolam versus dexmedetomidina, en funciones hemodinámicas, ventilación y profundidad de hipnosis, en pacientes STOP-Bang positivo bajo anestesia espinal. MATERIALES Y MÉTODOS: Estudio clínico prospectivo, doble ciego, aleatorizado, pacientes bajo bloqueo espinal y sedación. Grupo MDZ (n = 29): midazolam 0,05 m g ∙ k g ­ 1 ; Grupo DEX (n = 29): dexmedetomidina 0,4 µ g ∙ k g ­ 1 ∙ h ­ 1 . Se evaluaron parámetros hemodinámicos (TAS, TAD y FC), ventilatorios (FR, SAT O2, ETCO2), profundidad de hipnosis (BIS), en periodos basal, 5, 10, 15, 30, 45 y 60 minutos. Criterios de inclusión: pacientes ASA I y II, 18 y 60 años, STOP-Bang positivos (+3 criterios positivos), ambos sexos. Criterios de exclusión: contraindicación de bloqueo central, alergia conocida a las drogas, negativa del paciente. Análisis estadístico: datos cualitativos se expresan como nº (%), se utilizó Test Chi-cuadrado y Test de Fisher. Datos cuantitativos promedio (desvío estándar), Test t. Nivel de significación: 0,05. RESULTADOS: Datos demográficos similares ambos grupos ( Tabla 1 ); el grupo DEX presentó menor FC 10' (p = 0,001), 15' (p = 0,002), 20' (p = 0,004). El grupo MDZ disminuyó la FR 5' (p < 0,0001), 10' (p < 0,0001), 15' (p = 0,001), 30' (p = 0,001), 45' (p = 0,0019), 60' (p = 0,001), y SAT O2 5' (p = 0,032), 10' (p = 0,033), 15' (p = 0,059), 30' (p = 0,033), 45' (p = 0,047), 60' (p = 0,028) comparado con DEX. El grupo MDZ disminuyó valores BIS 5' (p < 0,0001), 10' (p < 0,0001), 15' (p = 0,001), 30' (p < 0,001), 45' (p = 0,003), 60' (p = 0,038), comparado con DEX. CONCLUSIÓN: La sedación con dexmedetomidina en pacientes STOP Bang positivo bajo anestesia espinal, proporciona estabilidad hemodinámica, con mejor control de parámetros de ventilación y profundidad de hipnosis, en comparación con midazolam.

Índice de colapsabilidad de la vena cava inferior como predictor de hipotensión intraoperatoria / Inferior vena cava collapsibility index of the as a predictor of intraoperative hypotension

OBJECTIVE: To evaluate the lower vena cava Collapse Index (CI) as a predictor parameter of hypotensive episodes after general anesthesia induction in ASA I and II patients who were scheduled for elective surgery. MATERIALS AND METHODS: A prospective, observational and simple blind study was designed. A sample of 80 patients was recruited. In the preoperative stage, they underwent protocolarized sedation and CI was obtained. Prior to induction, the baseline values ​​of heart rate, non-invasive mean arterial pressure and continuous electrocardiographic tracing in DII were noted. In the post-orotracheal intubation stage, the aforementioned hemodynamic monitoring variables were recorded manually for 10 minutes. RESULTS: The data of 78 individuals are presented. After anesthetic induction, 8 (10.3%) patients developed hypotension. The adjustment of the univariate logistic regression model for CI shows a good diagnostic capacity, with the area under the ROC curve equal to 0.76. The chance of presenting hypotension is increased by 62% by increasing the CI by 5 points (p = 0.003). Regarding the negative predictive value, we found that with values ​​corresponding to the cutoff points between 39% and 46%, a probability of at least 93.1% of not presenting hypotension was obtained. The optimal cutoff point of the CI to predict hypotension is estimated at 43%, with a sensitivity of 62.5% and a specificity of 92.9%. CONCLUSION: A lower IC was associated with a lower probability of developing intraoperative hypotension. The use of this tool could be useful to anticipate which patients will be prone to intra-surgical hypotension.

OBJETIVO: Evaluar el índice de colapsabilidad (IC) de la vena cava inferior (VCI) como predictor de episodios hipotensivos posinducción de anestesia general en cirugía electiva de pacientes ASA I y II. MATERIALES Y MÉTODOS: Se diseñó un estudio prospectivo, observacional y simple ciego. Se reclutó una muestra de 80 pacientes. En etapa preoperatoria fueron sometidos a una sedación protocolizada y se obtuvo el IC. Previo a la inducción, se anotaron los valores basales de la frecuencia cardíaca, la presión arterial media y el trazado electrocardiográfico continuo en DII. Posintubación orotraqueal, se registraron manualmente las variables hemodinámicas mencionadas durante 10 minutos. RESULTADOS: Se presentan datos de 78 individuos. Luego de la inducción, 8 (10,3%) pacientes desarrollaron hipotensión. El ajuste del modelo de regresión logística univariado para IC muestra una buena capacidad diagnóstica, siendo el área bajo la curva ROC igual a 0,76. La chance de presentar hipotensión se incrementa en un 62% al aumentar el IC en 5 puntos (p = 0,003). En cuanto al valor predictivo negativo, encontramos que con valores correspondientes a los puntos de corte entre 39% y 46%, se obtenía una probabilidad de 93,1% de no presentar hipotensión. El punto de corte óptimo del IC para predecir hipotensión se estima en 43%, con una sensibilidad del 62,5% y una especificidad del 92,9%. CONCLUSIÓN: Un menor IC se asoció con una menor probabilidad de desarrollar hipotensión intraoperatoria. El uso de esta herramienta podría ser de utilidad para anticipar qué pacientes serán propensos a hipotensión intraquirúrgica.

Perfusión intravenosa de remifentanilo controlada por ordenador: efectos, consumo, concentración efectiva / Intravenous infusion of remifentanil computer controlled: effects, consumption, effective concentration

Introducción: El objetivo fue comprobar si los sistemas de perfusión guiados por ordenador TCI (Target Control Infusion) estimando concentraciones plasmáticas (Cp), modulan condiciones hemodinámicas, consumo de remifentanil y concentraciones sitio efecto (Ce), en colecistectomía videolaparoscópica (CVL). Material y Métodos: Estudio clínico prospectivo, aleatorizado en pacientes ASA I, dos grupos: GRUPO PC (n = 12) remifentanil 0.5 mcg x kg-1 x min-1 y GRUPO TCI (n = 12) TCI remifentanil Cp 4 ng x ml-1 (Modelo Minto, Ke sub 0 0,595/min). Ambas perfusiones disminuidas 50% posintubación. Se registraron Tensión Arterial Sistólica (TAS), Tensión Arterial Diastólica (TAD) y Frecuencia Cardíaca (FC), remifentanil consumido y Ce, basal, posintubación, posincisión y finalización cirugía. Resultados: Sin diferencias entre grupos variables antropométricas, tiempos quirúrgico y de anestesia. Se halló diferencia G PC vs G TCI en FC (X ± de) posintubación 63,2 ± 12,2 vs 76,6 ± 13 (p = 0,014). Dentro grupos, G PC posintubación TAS 96,9 ± 18,5 (p = 0,0009), TAD 57,7 ± 15,2 (p = 0,0006) y FC 63,2 ± 12,2 (p = 0,010). Consumo de remifentanil G PC vs G TCI posintubación 216,2 ± 91,6 vs 102,4 ± 14,8 (p < 0,0001), posincisión 381,4 ± 185,4 vs 184,1 ± 39,6 (p = 0,0002) y fin de cirugía 2310 ± 912,8 vs 1642,4 ± 607,8 (p = ,028). Ce remifentanil posintubación 7,4 ± 1,6 vs 3,6 ± 0,2 (p < 0,0001), posincisión 6,1 ± 1,7 vs 2,2 ± 0,3 (p < 0,0001). Hipotensión G PC posintubación (50% p < 0,007), posincisión (33,3% p < 0,047), necesidad de efedrina dos pacientes G PC. Conclusión: La perfusión de remifentanil controlada por ordenador Cp de 4 ng/ml produjo en nuestro grupo de pacientes mejores condiciones hemodinámicas durante el intraoperatorio, comparada con perfusión continua de 0.5 mcg x kg-1 x min-1, en CVL. La mejoría se atribuiría a la adecuada concentración de remifentanil en sitio de efecto, permitiendo además disminuir el consumo de la droga.

Perfusión intravenosa de remifentanilo controlada por ordenador: efectos, consumo, concentración efectiva / Intravenous infusion of remifentanil computer controlled: effects, consumption, effective concentration

Introducción: El objetivo fue comprobar si los sistemas de perfusión guiados por ordenador TCI (Target Control Infusion) estimando concentraciones plasmáticas (Cp), modulan condiciones hemodinámicas, consumo de remifentanil y concentraciones sitio efecto (Ce), en colecistectomía videolaparoscópica (CVL). Material y Métodos: Estudio clínico prospectivo, aleatorizado en pacientes ASA I, dos grupos: GRUPO PC (n = 12) remifentanil 0.5 mcg x kg-1 x min-1 y GRUPO TCI (n = 12) TCI remifentanil Cp 4 ng x ml-1 (Modelo Minto, Ke sub 0 0,595/min). Ambas perfusiones disminuidas 50% posintubación. Se registraron Tensión Arterial Sistólica (TAS), Tensión Arterial Diastólica (TAD) y Frecuencia Cardíaca (FC), remifentanil consumido y Ce, basal, posintubación, posincisión y finalización cirugía. Resultados: Sin diferencias entre grupos variables antropométricas, tiempos quirúrgico y de anestesia. Se halló diferencia G PC vs G TCI en FC (X ± de) posintubación 63,2 ± 12,2 vs 76,6 ± 13 (p = 0,014). Dentro grupos, G PC posintubación TAS 96,9 ± 18,5 (p = 0,0009), TAD 57,7 ± 15,2 (p = 0,0006) y FC 63,2 ± 12,2 (p = 0,010). Consumo de remifentanil G PC vs G TCI posintubación 216,2 ± 91,6 vs 102,4 ± 14,8 (p < 0,0001), posincisión 381,4 ± 185,4 vs 184,1 ± 39,6 (p = 0,0002) y fin de cirugía 2310 ± 912,8 vs 1642,4 ± 607,8 (p = ,028). Ce remifentanil posintubación 7,4 ± 1,6 vs 3,6 ± 0,2 (p < 0,0001), posincisión 6,1 ± 1,7 vs 2,2 ± 0,3 (p < 0,0001). Hipotensión G PC posintubación (50% p < 0,007), posincisión (33,3% p < 0,047), necesidad de efedrina dos pacientes G PC. Conclusión: La perfusión de remifentanil controlada por ordenador Cp de 4 ng/ml produjo en nuestro grupo de pacientes mejores condiciones hemodinámicas durante el intraoperatorio, comparada con perfusión continua de 0.5 mcg x kg-1 x min-1, en CVL. La mejoría se atribuiría a la adecuada concentración de remifentanil en sitio de efecto, permitiendo además disminuir el consumo de la droga. (AU)

Halothane anesthesia in mice: effect on the phagocytic activity and respiratory burst of peritoneal macrophages.

OBJECTIVE: To study the effects of halothane anesthesia in mice not undergoing surgery on elements of the inflammatory and stress response; this involved assessment of the phagocytic activity and respiratory burst of peritoneal macrophages as well as plasma corticosterone levels and peripheral leukocyte counts. METHODS: There were 2 experimental groups, i.e. mice anesthetized with halothane 1.5% in oxygen for 40 min and a control group of mice subjected to the same manipulations but no anesthesia. At the end of the anesthetic or sham procedure, peritoneal macrophages were evaluated for phagocytic and lytic activity after an immune challenge and spontaneous respiratory burst (chemoluminiscence). Plasma corticosterone and leukocyte counts in peripheral blood were evaluated as indicators of the stress response. RESULTS: In halothane-anesthetized mice, increased numbers and activity of phagocytic cells were found, with regard to the number of ingested and digested particles, compared to the nonanesthetized group. The ex vivo peritoneal macrophage respiratory burst without antigenic stimulation also showed a higher response in anesthetized mice compared with the nonanesthetized controls. Halothane administration did not alter corticosterone levels. Treated and control mice displayed similar leukocyte profiles in peripheral blood, except for lower lymphocyte counts in the controls compared to the halothane group. Typical correlation between corticosterone and leukocyte subsets, together with a high positive correlation between plasma corticosterone and phagocytic cell counts, were found only in the control group. CONCLUSION: Halothane anesthesia might have beneficial effects on the inflammatory response mediated by phagocytes, namely the activity and efficiency of peritoneal macrophages, in a setting where plasma corticosterone and peripheral leukocyte counts were not affected.