Use of noninvasive measurement of the indocyanine green plasma disappearance rate in patients with septic shock.

OBJECTIVE: Our aim was to analyse the relation between serial values of the indocyanine green plasma disappearance rate (ICG-PDR) with hospital mortality in the first 48 hours of ICU admission in patients with septic shock. METHODS: A prospective observational study was carried out over 12 months of patients admitted to the ICU with septic shock. Each patient underwent noninvasive determination of ICG-PDR at 24 and 48 hours with the LiMON® module. Follow-up was performed until hospital discharge or exitus. RESULTS: 63 patients. Age 61.1±12.3 years. 60.3% men. SOFA score on admission 8.7±3.3, APACHE II score was 27.9±10.7 points. A total of 44.4% of patients died. The ICG-PDR values in the first 24 hours of ICU admission were lower in nonsurvivors: 10.5 (5.7-13.0)%/min vs. 15.9 (11.4-28.0)%/min, p <0.001. Furthermore, in nonsurvivors, there was no improvement in ICG-PDR between 24 h and 48 h, while in survivors, there was an increase of 25%: 15.9 (11.4-28.0)%/min and 20.9 (18.0-27.0)%/min, p=0.020. The silhouette measure of ICG-PDR cohesion and separation for the clusters analysed (nonsurvivors and survivors) was satisfactory (0.6). ICG-PDR<11.7%/min was related to in-hospital mortality, ICG-PDR> 18%/min to survival, and the interval between 11.7% and 18%/min covered a range of uncertainty. In the two-stage cluster, ICG-PDR, SOFA and APACHE II present satisfactory predictive scores 24 hours after patient admission. CONCLUSIONS: ICG-PDR in our setting is a useful clinical prognostic tool and could optimise the decision tree in patients with septic shock.

The hidden cost of disease: II. Impact of the first incidence of lameness on production and economic indicators of primiparous dairy cows.

Lameness is a persistent and underreported health and welfare problem in the dairy industry, resulting in reduced cow performance and profitability as well as early culling. The study objectives were (1) to quantify the impact of the first instance of lameness, at different stages of lactation, on production and economic performance, and (2) to further quantify the impacts of the first instance of lameness when only cows that remain in the herd for at least 100 d in milk (DIM) and those that remain for 305 DIM are included in the analysis. A retrospective longitudinal study was conducted using pre-existing data from animal health records and Dairy Herd Improvement Association records. Data were edited based on selected inclusion criteria, yielding a data set containing records from 15,159 first-lactation Holstein cows from 120 herds with year of first calving between 2003 and 2014. Lame cows were assigned to 1 of 4 groups based on when in the lactation the first event of lameness occurred: transition (1-21 DIM), early lactation (22-100 DIM), mid-lactation (101-200 DIM), or late lactation (201+ DIM). Mid- and late-lactation lame cows were also stratified by cumulative milk yield before the lameness event. Healthy cows (i.e., no recorded lameness event) were randomly assigned for each lactation stage, with mid-lactation healthy and late-lactation healthy cows similarly stratified. Production performance (cumulative milk, fat, and protein yield) and economic performance [milk value, margin over feed cost (MOFC), and gross profit] were analyzed using a mixed model with herd as a random effect. Cumulative milk yields were 811 to 1,290 kg lower for lame cows than for healthy cows, with milk component yields undergoing similar reductions. Reductions in milk yield contributed to losses in milk value (-Can$527 to -Can$1,083; -US$419 to -US$862) and MOFC (-Can$510 to -Can$774; -US$406 to -US$616). Higher losses were reported using gross profit (-Can$753 to -Can$1,052; -US$599 to -US$837), which includes all lameness-related costs. Production and performance losses were smaller when 100 DIM and 305 DIM thresholds were applied (i.e., exclusion of cows culled before 100 and 305 DIM, respectively), however, mid- and late-lactation lame cows maintained high levels of significant losses for all 6 variables analyzed. Lameness also led to higher levels of culling, masking losses for transition and early-lactation lame cows in the 305-DIM analysis. Increasing producer understanding of the costs associated with lameness not only serves to provide insight to producers for more informed culling decisions, but may also help producers weigh the costs of adopting new methods and technologies targeted at reducing on-farm lameness.

The hidden cost of disease: I. Impact of the first incidence of mastitis on production and economic indicators of primiparous dairy cows.

Mastitis is a highly prevalent disease, which negatively affects cow performance, profitability, welfare, and longevity. The objectives of this study were (1) to quantify the impact of the first instance of mastitis, at different stages of lactation, on production and economic performance, and (2) to further quantify the impact of the first instance of mastitis when only cows that remain in the herd for at least 100 d in milk (DIM) and those that remain for 305 DIM are included in the analysis. A retrospective longitudinal study was conducted using data from existing animal health record files and Dairy Herd Improvement records. After editing based on selected inclusion criteria and completeness of health records, data consisted of records from first-lactation Holstein cows, from 120 herds, that calved for the first time between 2003 and 2014, inclusive. Mastitic cows were assigned to 1 of 4 groups based on when in the lactation the first event of mastitis occurred: transition (1-21 DIM), early lactation (22-100 DIM), mid lactation (101-200 DIM), or late lactation (201+ DIM). Mid-lactation and late-lactation mastitic cows were also stratified by cumulative milk yield before the mastitis event. Healthy cows (i.e., no recorded mastitis event) were randomly assigned for each lactation stage, with mid-lactation healthy and late-lactation healthy cows similarly stratified. Production performance (cumulative milk, fat, and protein yield) and economic performance [milk value, margin over feed cost (MOFC), and gross profit] were analyzed using a mixed model with herd as a random effect. Significant losses in cumulative milk yield (-382 to -989 kg) and correspondingly lower fat and protein yields were found in mastitic cows, with transition and late-lactation mastitic cows having the highest losses. Drops in production translated to significant reductions in cumulative milk value (-Can$287 to -Can$591; -US$228 to -US$470), MOFC (-Can$243 to -Can$540; -US$193 to -US$429), and gross profit (-Can$649 to -Can$908; -US$516 to -US$722) for mastitic cows at all stages. Differences between mastitic and healthy cows in the early lactation and transition stages remained for all variables in the 100-DIM analysis, but, aside from gross profit, were nonsignificant in the 305-DIM analysis. Gross profit accounted for all costs associated with mastitis and thus continued to be lower for mastitic cows at all stages, even in the 305-DIM analysis in which culled cows were omitted (-Can$485 to -Can$979; -US$386 to -US$779). The research reflects the performance implications of mastitis, providing more information upon which the producer can make informed culling decisions and maximize both herd profitability and cow longevity.

Renal function at admission as a prognostic marker for patients hospitalised for a first episode of heart failure. Results of the PREDICE study. / Función renal al ingreso como marcador pronóstico en pacientes hospitalizados por un primer episodio de insuficiencia cardíaca. Resultados del estudio PREDICE.

BACKGROUND AND OBJECTIVE: Heart failure (HF) is a frequent condition that deteriorates quality of life and results in high morbidity and mortality. A considerable number of studies have been implemented in recent years to determine the factors that affect the prognosis of HF; however, few studies have assessed the prognosis of patients hospitalised for their first episode of HF. The aim of our study was to analyse the prognostic impact of renal function on patients hospitalised for a first episode of HF. MATERIAL AND METHODS: We recruited 600 patients hospitalised for a first episode of HF in 3 tertiary Spanish hospitals. We analysed the mortality risk during the first year of follow-up according to renal function at the time of admission. RESULTS: The patients with the highest degree of kidney failure at admission were older (P<.001), were more often women (p=.01) and presented a higher degree of dependence (P<.05), as well as a higher prevalence of arterial hypertension (P<.001), chronic renal failure (P<.001) and anaemia (P<.001). In the multivariate analysis, the degree of kidney failure at admission remained an independent predictor of increased mortality risk during the first year of follow-up. CONCLUSIONS: The presence of kidney failure at admission was a marker of poor prognosis in our cohort of patients hospitalised for a first episode of HF.

Delphi-RAND consensus of the Spanish Society of Internal Medicine on the controversies in anticoagulant therapy and prophylaxis in medical diseases. INTROMBIN Project (Uncertainty in thromboprophylaxis in internal medicine). / Consenso Delphi-RAND de la Sociedad Española de Medicina Interna sobre controversias en terapia y profilaxis anticoagulante en enfermedades médicas. Proyecto INTROMBIN (INcertidumbre en TROMBoprofilaxis en Medicina INterna).

The aim of this study was to determine the opinion of internists on the management of anticoagulation and thromboembolism prophylaxis in complex clinical scenarios in which the risk-benefit ratio of surgery is narrow and to develop a consensus document on the use of drugs anticoagulant therapy in this patient group. To this end, we identified by consensus the clinical areas of greatest uncertainty, a survey was created with 20 scenarios laid out in 40 clinical questions, and we reviewed the specific literature. The survey was distributed among the internists of the Spanish Society of Internal Medicine (SEMI) and was completed by 290 of its members. The consensus process was implemented by changing the Delphi-RAND appropriateness method in an anonymous, double-round process that enabled an expert panel to identify the areas of agreement and uncertainty. In our case, we also added the survey results to the panel, a methodological innovation that helps provide additional information on the standard clinical practice. The result of the process is a set of 19 recommendations formulated by SEMI experts, which helps establish guidelines for action on anticoagulant therapy in complex scenarios (high risk or active haemorrhage, short life expectancy, coexistence of antiplatelet therapy or comorbidities such as kidney disease and liver disease), which are not uncommon in standard clinical practice.

Contrasting energy allocation strategies of two sympatric Merluccius species in an upwelling system.

This study investigated the somatic growth and energy allocation strategy of two sympatric hake species (Merluccius polli and Merluccius senegalensis), coexisting under the strong influence of the Mauritanian upwelling. The results revealed that ontogeny, bathymetry, geography and reproduction shaped the differences found between the condition dynamics of the two species. Aside from species-specific differences, individuals were observed in better condition in the northernmost area (more influenced by the permanent upwelling) and in the deepest waters, probably the most favourable habitat for Merluccius spp. Both species also displayed contrasting trade-offs in energy allocation probably due to the dissimilarity of their habitats, which favours the existence of divergent adaptive strategies in response to different ontogenic requirements. It was hypothesized that M. polli invests in mass and energy reserves while sacrificing growth, as larger sizes may not provide an ecological advantage in a deeper and more stable environment. Moreover, M. senegalensis capitalizes on a steady growth without major disruptions, enabling earlier spawning at the expense of a lower somatic mass, which is fitting to a less stable shallower environment. This study sheds new light on differences in the biological traits and life strategies of Merluccius spp., which permit their overlap in a complex upwelling system and may contribute to the long-lasting scientific-based management of these species.

Assessment of thromboprophylaxis in medical patients hospitalized in Andalusia. A multicenter study. / Adecuación de tromboprofilaxis en pacientes médicos hospitalizados en Andalucía. Estudio multicéntrico.

BACKGROUND AND OBJECTIVES: Hospitalized patients are a population at risk for venous thromboembolism (VTE). The PRETEMED-2007 clinical practice guidelines help identify high-risk medical patients who are suited to thromboprophylaxis. These guidelines therefore provide a standard for prophylaxis in such patients. We evaluated the risk of VTE and the adjustment of thromboprophylaxis to the standards of the PRETEMED-2007 guidelines in patients hospitalized in internal medicine departments. PATIENTS AND METHODS: An observational, cross-sectional multicenter study was performed in 2010 in 16 hospitals in Andalusia and included 20 consecutive patients per center. The study variables were age, sex, risk factors for VTE and hemorrhage, the risk-adjusted PRETEMED of VTE, adjustment of thromboembolic prophylaxis at admission and at discharge and hospital mortality. RESULTS: The study included 293 patients (57.8% men) with a mean age of 69 (±15) years. The most common triggers for VTE were acute severe infection (27.3%) and neoplasia (16.4%). Some 43.4% of the patients presented a risk of hemorrhage. The risk of VTE at admission and discharge was high in 47.8% and 31% and moderate in 8.2% and 10.6%, respectively. A total of 91.7% and 17.3% of the patients underwent prophylaxis with low-molecular-weight heparin on admission and at discharge, respectively. The prescription was appropriate for 59.9% of the patients at admission (overutilization 38.4%, underutilization 1.7%) and for 74.7% at discharge (overutilization 5.4%, underutilization 19.9%). The adjustment was greater in patients older than 60 years and with greater hemorrhagic risk. CONCLUSIONS: For 60% of the patients admitted to the departments of internal medicine in Andalusia, the thromboprophylaxis was appropriate. The inadequacy of thromboprophylaxis (40%) is mostly due to overutilization. These results suggest significant space for improvement.

[Are the guidelines guiding us reliable? Evaluation of the Spanish clinical practice guidelines]. / Las guías que nos guían son fiables? Evaluación de las guías de práctica clínica españolas.

BACKGROUND AND OBJECTIVE: There is a large proliferation of clinical practice guidelines (CPG), there being doubts on inconsistencies between the recommendations made and internal incongruencies, that affect the role of the guidelines as instruments helping the clinicians. This study aims to analyze the quality of a group of Spanish CPG and to assess the feasibility of use and consistency of the AGREE Instrument in its Spanish version, designed to evaluate the CPG. METHOD: A total of 278 CPG produced in Spain between January 1990 and December 2002 were identified. The originals of 61 guidelines were recovered from their authors and passed to the AGREE Instrument independently by four raters. Quality of the guidelines feasibility and reproducibility of AGREE were analyzed. RESULTS: For all the attributes of AGREE except in the editorial independence, more than 60% of the guidelines evaluated obtained a poor quality score, there being no domain in which more than 10% of the guidelines was excellent. The worst grading areas are those of applicability, participation and rigour of development of the guidelines. Of the 61 guidelines evaluated, the reviewers graded 25 as "very poor quality", 26 as "non recommendable" and 6 and 4 as "recommendable" or "highly recommendable", respectively. Interrater consistency was high. CONCLUSIONS: The mean quality of the Spanish guidelines evaluated is very low. The AGREE Instrument in its Spanish version is consistent for the Spanish guidelines and easy to use.