Actinomicosis musculoesquelética por Actinomyces europaeus / Musculoskeletal actinomycosis caused by Actinomyces europaeus

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El índice palliative performance scale como escala pronóstica en atención domiciliaria / The Palliative Performance Scale as a prognostic scale in home care

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The Impact of Head-of-Bed Positioning and Transducer Location on Cerebral Perfusion Pressure Measurement.

INTRODUCTION: Head-of-bed (HOB) elevation is the standard of care for patients with intracranial pressure monitoring at risk for intracranial hypertension. Measurement of cerebral perfusion pressure (CPP) based on HOB elevation and arterial transducer position has not been adequately studied. METHODS: This is a planned secondary analysis of prospectively collected data in which paired, serial arterial blood pressure (ABP), intracranial pressure, and CPP measures were obtained once per day for 3 days, with measures leveled at the tragus (Tg) and the phlebostatic axis (PA). The HOB position was recorded for all paired readings. RESULTS: From 136 subjects, ABP and CPP values were lower when the transducer was leveled at the Tg, compared with the PA (P < .001); these differences persisted regardless of HOB position. CONCLUSION: The difference in CPP when ABP is referenced at the Tg versus PA is not consistently attributed to HOB elevation.

Pupillometry Trends in the Setting of Increased Intracranial Pressure.

Serial pupil examinations remain a mainstay of neurological assessments performed by neuroscience nurses. Integration of pupillometer technology has increased in recent years, because of its ability to address limitations of manual examinations and to evaluate trended data over time. Preliminary research has linked pupillometer values to intracranial pressure (ICP) values, but data on pupillary changes in the setting of increased ICP remain sparse. The purpose of this study was to determine trends in pupillometer values in the setting of increased ICP among critically ill patients with neurological injury. This is a secondary analysis of data where serial pupillometer and ICP readings were recorded hourly on adult patients with neurological injury necessitating critical care management. More than 2100 paired serial pupillometer and ICP readings were obtained from 76 subjects, with a total of 2107 paired readings for the left eye and 2175 for the right eye. There were statistically significant differences in pupillometry values in the setting of increased ICP. Time series analysis indicates that spikes in ICP values resulted in corresponding variations in pupillometer values. Use of automated pupillometry remains a value adjunct to traditional invasive therapies. Evaluation of trended data may provide insight into ICP elevations in the absence of invasive monitoring and warrants additional research.

Evidence-Based Review of Clinical Trials in Neurocritical Care.

Neurocritical care is a rapidly growing specialty of complex care for the critically ill patient with neurological injury. This rapid growth has led to an increase in the number of important clinical trials to guide clinical practice and evidence-based care of the critically ill patient with neurological injury. Specialty-trained critical care nurses and advanced practice providers are integral members of neurocritical care teams and must remain informed about pivotal trials shaping practice recommendations. This article presents a summary of recent trials that have affected current practice and influenced care recommendations in the neurocritical care setting.

¿Cómo son los últimos meses de vida de los pacientes con insuficiencia renal crónica avanzada en los que se desestima el tratamiento con hemodiálisis o con diálisis peritoneal? / What are the last months of life like for advanced chronic renal failure patients who are not considered candidates for treatment with haemodialysis or peritoneal dialysis?

OBJETIVO: Objetivo primario. Determinar la supervivencia y los factores predictores de supervivencia en pacientes con insuficiencia renal crónica avanzada (IRCA) desestimados para tratamiento renal sustitutivo (TRS). Objetivos secundarios. Describir: a) las características sociodemográficas de los pacientes y del cuidador principal; b) la etiología de la nefropatía y la comorbilidad asociada; c) variables clínicas de los pacientes cuando son incluidos en el programa; d) la evolución clínica en términos de tensión arterial (TA), número de episodios de sobrecarga hídrica, tratamientos recibidos, frecuencia de hospitalizaciones, causas de las mismas, lugar y causa del fallecimiento; e) la evolución de los parámetros analíticos; f) el grado de información del diagnóstico y del pronóstico del paciente y de la familia, y g) la actividad asistencial realizada por los equipos de soporte de atención paliativa domiciliaria (ESAPD) durante el seguimiento. Material y MÉTODO: DISEÑO: Estudio descriptivo longitudinal de cohorte histórica. Ámbito. ESAPD áreas 1, 5 y 7 de Madrid. Sujetos a estudio. Pacientes con IRCA que han sido considerados y desestimados para TRS. Criterios de selección.1) Pacientes con IRCA que han sido considerados y desestimados para depuración extrarrenal, y 2) el paciente y/o cuidador y/o familia acepta el seguimiento de la enfermedad por el ESAPD y/o por su médico de Atención Primaria. Tamaño de la muestra. Se seleccionaron todas las historias clínicas de los archivos desde la creación de los respectivos ESAPD, desde 1997 hasta diciembre del 2009. Variables analizadas.1) Respuesta principal: tiempo de supervivencia; 2) variables secundarias: 2.1) sociodemográficas paciente y cuidador principal; edad, sexo; cuidador principal: estado civil, parentesco; 2.2) variables relacionadas con la enfermedad renal; etiología de la nefropatía, motivo de exclusión de TRS, comorbilidad; 2.3) variables clínicas; grado de control TA a lo largo de la evolución de la enfermedad; se recoge la TA en sucesivas visitas; presencia o ausencia de alguno de los siguientes síntomas al inicio del programa: edemas, dolor, estreñimiento, prurito, disnea, insomnio, ansiedad, tristeza y deterioro cognitivo; número de episodios sobrecarga hídrica; causa de salida del programa; lugar del fallecimiento; causa del fallecimiento y síntomas presentes en situación de últimos días; 2.4) variables terapéuticas; número de fármacos al inicio del programa; número de fármacos a la salida del programa de los pacientes cuyo motivo de salida era el exitus; tipo de fármacos; número de transfusiones realizadas; 2.5) variables de ingresos hospitalarios; número de ingresos hospitalarios; causas de hospitalización; 2.6) variables analíticas; grado de control a lo largo de la enfermedad de parámetros analíticos hasta el fallecimiento; 2.7) variables del grado de información del diagnóstico y del pronóstico; 2.8) variables de actividad asistencial; número de visitas domiciliarias realizadas al paciente. RESULTADOS: N: 102 pacientes. Edad media: 79,62 (9,94) años. Etiología IRCA más frecuentes: vascular 37, no filiada 32, diabética 15.comorbilidad: SCG riesgo bajo 17, SCG riesgo medio 35, SCG riesgo alto 50. Ponderación media del índice de Charlson: 6,88 (2,5). Causa desestimación TRS: comorbilidad 47,5%, edad 25,7%, decisión paciente 22,8%, otras 4%. Grado información diagnóstico paciente y cuidador 57,9 y 94,4%, respectivamente. Grado información pronóstica paciente y cuidador 11,8 y 90%, respectivamente. Síntomas más frecuentes en primera visita: disnea 33,3%, prurito 30,4%, insomnio 34,3%, tristeza 36,3 y edemas 43,1%. Mediana consumo fármacos al inicio: 10, al final de seguimiento: 11. Número de transfusiones: 5. Número de ingresos hospitalarios: 50, por sobrecarga hídrica: 35, comorbilidad: 12, oliguria: 3. Causa exitus: IRCA 72,9%, enfermedad intercurrente 27,1%. Localización exitus: domicilio 39, hospital agudos 31, unidad cuidados paliativos 13, urgencias 2. Media visitas por ESAPD: 11,32, mediana: 6,5. Mediana supervivencia: 4 meses, supervivencia al año: 25%. Factores predictores de supervivencia: creatinina primera visita HZ 1,106 (IC 95% 1,01-1,20), p = 0,024; edad 71-80 años, HZ 4,42 (IC 95% 1,60-12,21), edad>81 años, HZ 2,97 (IC 95% 1,16-7,61). No se asoció a supervivencia niveles TA, volumen diuresis, niveles sodio, potasio, calcio, fósforo ni hemoglobina. CONCLUSIONES: Los pacientes con IRCA en los que se desestimó TRS y que fueron seguidos en su domicilio por unidades de cuidados paliativos a domicilio tuvieron una mediana de supervivencia de 4 meses, siendo la edad y la función renal residual factores predictores de supervivencia, sin que la comorbilidad ni los niveles de electrólitos, TA ni el volumen de diuresis se asocien a supervivencia. Durante el seguimiento la causa más frecuente de ingreso hospitalario fue la sobrecarga hídrica. La mayoría de los pacientes fallecieron por la progresión de la IRCA, en su domicilio o en una unidad de cuidados paliativos de media-larga estancia

OBJECTIVE: Primary OBJECTIVE: To determine survival and survival predictive factors in advanced chronic renal failure (ACRF) patients not considered candidates for renal replacement therapy (RRT). Secondary OBJECTIVES: To describe: a) the sociodemographic characteristics of the patients and the main caregiver; b) the aetiology and associated comorbidity of the nephropathy; c) the clinical variables of patients when they are included in the programme; d) the clinical outcome in terms of blood pressure (BP), episodes of fluid overload, treatments received, frequency of hospitalisation, causes of hospitalisation, place and cause of death; e) the evolution of analytical parameters; f) the degree of information about diagnosis and prognosis given to the patient and family, and g) care activity provided by the domiciliary palliative care support team (DPCST) during follow-up. Material and method: DESIGN: Longitudinal descriptive study of a historical cohort. Scope. DPCST of Madrid areas 1, 5 and 7. Study subjects. Patients with ACRF not considered candidates for RRT. Selection criteria.1) patients with ACRF considered and rejected for extra-renal depuration, and 2) the patient and/or caregiver and/or family had accepted follow-up by the DPCST and/or his or her Primary Care physician. Sample size. All clinical histories from the archives of the DPCSTs were selected, from 1997 up to December 2009. Variables analysed.1) Main answer: time of survival; 2) secondary variables: 2.1) sociodemographic characteristics of patient and caregiver: age and gender; main caregiver: marital status, kinship; 2.2) variables related to the renal disease: the aetiology of the nephropathy, reason for exclusion from RRT, comorbidity; 2.3) CLINICAL VARIABLES: degree of BP control during evolution of disease; measurements from several visits were collected; at initiation of programme, the presence or absence of the following was recorded: oedema, pain, constipation, pruritus, dyspnoea, insomnia, anxiety, sadness and cognitive deterioration; number of episodes of fluid overload; cause for exiting the programme; place of death; cause of death and symptoms observed in last days situation; 2.4) therapeutic variables: number of medications at beginning of programme, number of medications at time of exiting the programme, when cause of exit was death; type of medications; number of transfusions received; 2.5) variables of hospital admission: number of admissions; causes of admission; 2.6) analytical variables: degree of control of analytical parameters during illness until death; 2.7) variables on the degree of information about diagnosis and prognosis; 2.8) variables of care activity: number of domiciliary visits to the patient. RESULTS: N: 102 PATIENTS: Mean age: 76.92 (9.94) years. Aetiology ACRF: vascular 37, unknown origin 32, diabetic 15.comorbidity: low risk SCG 17; medium risk SCG 35; high risk SCG 50. Median Charlson comorbidity index: 6.88 (2.5). Cause for rejection for RRT: comorbidity 47.5%, age 25.7%, patient's decision 22.8%, others 4%. Degree of information about diagnosis to patient and caregiver: 57.9 and 94.4%, respectively. Degree of information about prognosis to patient and caregiver: 11.8 and 90%, respectively. Symptoms on first visit: dyspnoea 33.3%, pruritus 30.4%, insomnia 34.3%, sadness 36.3%, oedema 43.1%. Average medications at beginning of follow-up: 10. At the end: 11. Number of transfusions: 5. Number of hospital admissions: 50; caused by fluid overload: 35, comorbidity: 12, oliguria: 3. Cause of death: ACRF 72.9%, intercurrent illness 27.1%. Place of death: home 39, acute hospitalization ward 31, palliative care ward 13, emergency room 2. Average of visits by DPCST: 11.32, median 6.5. Average survival: 4 months, survival at one year: 25%. Predictive survival factors: creatinine on first visit HZ 1.106 (95% CI 1.01-1.20), p=.024; age 71-80 years, HZ 4.42 (95% CI 1.60-12.21), age>81 years, HZ 2.97 (95% CI 1.16-7.61). The following were not associated with survival rates: BP, volume of diuresis, levels of sodium, potassium, calcium, phosphorus and haemoglobin. CONCLUSIONS: ACRF patients rejected for RRT receiving domiciliary follow-up by palliative care teams had an average survival of 4 months; age and residual renal function were predictive factors for survival, whereas comorbidity, electrolyte levels, BP and diuresis were not. During follow-up, the most frequent cause of hospital admission was fluid overload. Most patients died because of disease progression, at home or in a palliative care medium-long term hospital ward

A National Trial on Differences in Cerebral Perfusion Pressure Values by Measurement Location.

BACKGROUND: Cerebral perfusion pressure (CPP) is a key parameter in management of brain injury with suspected impaired cerebral autoregulation. CPP is calculated by subtracting intracranial pressure (ICP) from mean arterial pressure (MAP). Despite consensus on importance of CPP monitoring, substantial variations exist on anatomical reference points used to measure arterial MAP when calculating CPP. This study aimed to identify differences in CPP values based on measurement location when using phlebostatic axis (PA) or tragus (Tg) as anatomical reference points. The secondary study aim was to determine impact of differences on patient outcomes at discharge. METHODS: This was a prospective, repeated measures, multi-site national trial. Adult ICU patients with neurological injury necessitating ICP and CPP monitoring were consecutively enrolled from seven sites. Daily MAP/ICP/CPP values were gathered with the arterial transducer at the PA, followed by the Tg as anatomical reference points. RESULTS: A total of 136 subjects were enrolled, resulting in 324 paired observations. There were significant differences for CPP when comparing values obtained at PA and Tg reference points (p < 0.000). Differences remained significant in repeated measures model when controlling for clinical factors (mean CPP-PA = 80.77, mean CPP-Tg = 70.61, p < 0.000). When categorizing CPP as binary endpoint, 18.8% of values were identified as adequate with PA values, yet inadequate with CPP values measured at the Tg. CONCLUSION: Findings identify numerical differences for CPP based on anatomical reference location and highlight importance of a standard reference point for both clinical practice and future trials to limit practice variations and heterogeneity of findings.

Correlations Between Hourly Pupillometer Readings and Intracranial Pressure Values.

INTRODUCTION: Automated pupillometry is emerging as a mainstay in neurocritical care primarily because it overcomes limitations of manual pupillary examinations. Although several recent studies show improved assessment accuracy with a pupillometer, few investigate clinical use, specifically how well parameters correlate with multimodality monitoring and outcomes. The primary aim of this study was to examine correlations between serial pupillometer readings and intracranial pressure (ICP) values among neurocritically ill patients. DESIGN: Prospective cohort, repeated measures. SAMPLE: The study sample was composed of adult patients with neurological injury who were admitted to intensive care unit, requiring hourly neurological assessment and pupillary checks within a level I trauma, urban, academic medical center. PROCEDURES: Hourly pupillometer readings and corresponding ICP values were consecutively recorded for 72 hours after intensive care unit admission. RESULTS: Serial assessments resulted in more than 2100 pupillometer readings from 76 subjects. Mean age of the study sample was 55.4 years, with a mean Glasgow Coma Scale score of 8.9. The mean pupillometer values for the enrolled subjects included left constriction velocity of 1.22, left neurological pupil index of 4.21, left pupil size of 2.69, right constriction velocity of 1.18, right neurological pupil index of 4.18, and right pupil size of 2.57. The mean ICP of the study sample was 12, with mean cerebral perfusion pressure of 77. Pupillometer values significantly correlated with ICP values in bivariate (P < .001, r = 0.13-0.23) and multivariate regression models (F(6) = 17.63, P < .001). CONCLUSIONS: Automated pupillometry in neurocritical care is a valuable adjunct to traditional invasive monitoring. Integration of routine pupillometer assessments not only improves accuracy of examinations but also correlates with ICP values.

Successful treatment of recalcitrant discoid lupus erythematosus with ustekinumab.

We report a 52-year old woman with a 28-year historyof disfiguring facial discoid lupus erythematosus(DLE), persistent despite both classical therapiesand rituximab. Ustekinumab 45 mg was started incombination with methotrexate and intralesionalcorticosteroids. Methotrexate and intralesionalcorticosteroids were withdrawn 30 months later andustekinumab maintained as monotherapy. Fortyeight months later stable improvement was achievedwithout side effects. Only nine patients with cutaneouslupus erythematosus (CLE) treated with ustekinumabhave been reported to date. Ustekinumab could be apromising alternative in severe and recalcitrant casesof CLE. Possibly, the Th17-inflammation pathway isplaying a role in these patients.

Úlcera crónica en el hombro y caquexia / Non-healing shoulder ulcer and cachexia

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