Severe traumatic disease in ICU: an analysis of mortality during first 48 hours

RESUMEN : OBJETIVOS: Analizar la mortalidad precoz hospitalaria de los pacientes con enfermedad traumática grave (primeras 48 horas de ingreso en Medicina Intensiva -UCI). MÉTODO: Estudio analítico unicéntrico y retrospectivo de los pacientes con enfermedad traumática grave ingresados en Medicina Intensiva del Hospital Universitario Marqués de Valdecilla. Período: 2015-2020. Se realizó un análisis estratificado en función de la edad y de la presencia de shock hemorrágico. Se usó la prueba t-student o prueba U de Mann-Whitney para la comparación de variables cuantitativas. Las variables categóricas fueron evaluadas con la prueba X2 o el test exacto de Fisher. RESULTADOS: La mortalidad en el periodo evaluado fue de 11,9% (97/815). De ellos, 28 pacientes (28,9%) fallecieron en las primeras 48 horas. La media fue de 28% anticoagulados, siendo la precipitación (28,6%) el principal mecanismo del traumatismo. A su llegada a UCI destacaba una ECG de 3 (IQR 3-7) y un lactato de 43 (IQR 21-81). El 89% presentaba TCE y el 42,9% tenía lesiones esqueléticas. La causa del exitus fue shock hemorrágico en 12 pacientes (42,9%). La mediana de tiempo desde ingreso el exitus fue de 5 horas (IQR 14-32). Los pacientes añosos (> 65 años) se caracterizaron de modo significativo, por recibir anticoagulación (53,3% vs. 9; 0,002) y caída accidental (46,7% vs 0; p: 0,01) como mecanismo principal del trauma. Los pacientes con shock hemorrágico presentaron a su ingreso hospitalario un nivel de lactato significativamente superior y el tiempo transcurrido hasta el óbito resultó menor (5 horas (IQR 3-9,5) vs. 30 horas (IQR 14-47)). Además, presentaron traumatismo pélvico (50% vs 12,5%; p: 0,04) y/o esquelético (66,7% vs. 25%; p: 0,027) como principales lesiones. CONCLUSIONES: La mortalidad precoz en la serie estudiada alcanzó el 28,8%. El shock hemorrágico fue la principal causa de mortalidad precoz. Los pacientes añosos son un grupo vulnerable por presentar la misma gravedad ante lesiones de menor energía (caídas accidentales) y por estar bajo tratamiento anticoagulante. El abordaje global y transversal en las fases iniciales resulta crucial para mejorar resultados funcionales.ABSTRACT : BJECTIVES: This project was developed to analyze the early mortality of patients with severe traumatic disease (in the first 48 hours from their admission to Intensive Care Unit -ICU). METHODS: This is a retrospective unicentral analytical study of patients with severe traumatic disease admitted to Intensive Care Unit of Marqués de Valdecilla University Hospital during 2015- 2020. The patients were stratified according to age and the presence of hemorrhagic shock. The t student and Mann-Whitney U tests were used to compare quantitative variables. Categorical variables were evaluated with X2 and Fisher exact tests. RESULTS: Mortality during the evaluated period was 11,9% (97/815). Of them, 28 patients (28,9%) died in the first 48 hours. On average 28% of the patients were anticoagulated and the main mechanism of trauma was the precipitation (28,6%). At the moment of the arrival at the ICU, an ECG of 3 (IQR 3-7) and a lactate of 43 (IQR 21-81) stood out. 89% had TBI and 42,9% had skeletal lesions. The etiology of death was hemorrhagic shock in 12 patients (42,9%). The median time from admission to death was 5 hours (IQR 14-32). Elderly patients (>65 years) were significantly characterized by receiving anticoagulation (53,3% vs.9; 0,002) and accidental falls (46,7% vs 0; 0,01) as mechanisms of trauma. Patients with hemorrhagic shock presented a significantly higher lactate level at hospital admission and the time elapsed until death was shorter (5 hours (IQR 3-9.5) vs. 30 hours (IQR 14-47)). On top of that, they suffered pelvic trauma (50% vs. 12.5%; p: 0.04) and/or skeletal (66.7% vs. 25%; p: 0.027) as main injuries. CONCLUSIONS: Early mortality in the studied series reached 28.8%. Hemorrhagic shock was the main cause of early mortality. The elderly is a vulnerable group since they present same severity with lower energy injuries (accidental falls) and because they take anticoagulant treatment. The global and holistic approach in the initial phases is crucial to improve functional resultsGrado en Medicin

Switch to ocrelizumab in MS patients treated with natalizumab in extended interval dosing at high risk of PML: A 96-week follow-up pilot study

We aimed to assess the long-term safety and effectiveness of ocrelizumab in a cohort of patients with multiple sclerosis (MS) at high risk of progressive multifocal leukoencephalopathy (PML), previously treated with natalizumab in extending interval dosing (EID), who switched to ocrelizumab and to compare them with patients who continued EID-natalizumab. Thirty MS patients previously treated with natalizumab in EID (every 8 weeks) were included in this observational retrospective cohort study. Among them, 17 patients were switched to ocrelizumab and 13 continued with EID-natalizumab. Except for the John Cunningham virus (JCV) index, no significant differences were detected between both groups. Main outcome measures included: annualized relapse rate (ARR), radiological activity, disability progression, and the NEDA-3 index. Patients were followed for 96 weeks. The median washout period in ocrelizumab-switchers was 6 weeks. Among them, AAR and radiological activity during follow-up were 0.03, without significant differences in comparison with the previous period on natalizumab-EID. The comparison between ocrelizumab-switchers and patients continuing on EID-natalizumab showed no significant differences in AAR, radiological activity, or disability progression. However, the proportion of patients maintaining a NEDA-3 status in week 96 was slightly superior among ocrelizumab-switchers (94 vs 69%). No serious adverse events were observed in any group. In conclusion, switching from EID-natalizumab to ocrelizumab can be considered as a therapeutic option, particularly in patients with MS at high risk of PML, to mitigate the risks of both PML and disease reactivationFunding: This study received funding from IDIVAL (CSI 19/51 and CSI21/73). The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publicatio