Approach to the patient with tear duct pathology: Surgical indications

Introduction and objective: To carry out a update review on the current diagnoses and therapeutic indications of tear duct obstruction (NLO) and propose a simple, early and practical clinical management. Method: Review of published literature regarding NLO and the current way of approaching this pathology. Results: The alteration of the natural tear flow (epiphora) may have a functional or anatomical origin. Functional obstructions are secondary to the failure of the tear pump, while the anatomical obstruction is caused by a physical obstacle along the tear duct that prevents drainage in the nasal cavity. Pseudoepiphora (tearing), on the other hand, is secondary to the presence of pathology of the ocular surface (dry eye) or secondary to mechanical, chemical, infectious or psychic stimuli. Up to 40% of patients referred to ophthalmology consultations for tearing / epiphora, have a dry eye with tear reflex, without anatomical obstruction of the tear duct. Conclusions: Tearing is one of the most frequent symptoms in ophthalmology consultations. However, the etiological factors that can lead to this complaint are very numerous. A multidisciplinary study (ophthalmology and ENT) is essential to make a correct etiological diagnosis. The success of tear surgery lies in a correct surgical indication.Introducción y objetivo: Realizar una revisión y actualización del diagnóstico e indicaciones terapéuticas de la obstrucción de la vía nasolagrimal (ONL), así como un abordaje clínico sencillo, precoz y práctico. Método: revisión de la literatura publicada referente a la ONL y sobre la manera actual de enfocar esta patología. Resultados: El lagrimeo excesivo (epífora) puede tener un origen funcional o anatómico. Las obstrucciones funcionales son secundarias al fracaso de la bomba lagrimal, mientras que la obstrucción anatómica es causada por un obstáculo físico a lo largo de la vía lagrimal que impide el drenaje de la misma en la cavidad nasal. La pseudoepífora (lagrimeo reflejo), por el contrario, es secundaria a la presencia de patología de la superficie ocular (ojo seco) o a estímulos mecánicos, químicos, infecciosos o psíquicos. Hasta un 40% de los pacientes referidos a consultas de oftalmología por lagrimeo/epífora, presentan un ojo seco con lagrimeo reflejo, sin obstrucción anatómica de la vía lagrimal. Conclusiones: El lagrimeo es uno de los síntomas más frecuentes en las consultas de oftalmología. Sin embargo, son muy numerosos los factores etiológicos que pueden conducir a esta queja. Es fundamental un estudio multidisciplinar (oftalmología y otorrinolaringología) para realizar un correcto diagnóstico. El éxito de la cirugía lagrimal reside en una correcta indicación quirúrgica

Prediction of long-term outcomes of HIV-infected patients developing non-AIDS events using a multistate approach

Outcomes of people living with HIV (PLWH) developing non-AIDS events (NAEs) remain poorly defined. We aimed to classify NAEs according to severity, and to describe clinical outcomes and prognostic factors after NAE occurrence using data from CoRIS, a large Spanish HIV cohort from 2004 to 2013. Prospective multicenter cohort study. Using a multistate approach we estimated 3 transition probabilities: from alive and NAE-free to alive and NAE-experienced ("NAE development"); from alive and NAE-experienced to death ("Death after NAE"); and from alive and NAE-free to death ("Death without NAE"). We analyzed the effect of different covariates, including demographic, immunologic and virologic data, on death or NAE development, based on estimates of hazard ratios (HR). We focused on the transition "Death after NAE". 8,789 PLWH were followed-up until death, cohort censoring or loss to follow-up. 792 first incident NAEs occurred in 9.01% PLWH (incidence rate 28.76; 95% confidence interval [CI], 26.80-30.84, per 1000 patient-years). 112 (14.14%) NAE-experienced PLWH and 240 (2.73%) NAE-free PLWH died. Adjusted HR for the transition "Death after NAE" was 12.1 (95%CI, 4.90-29.89). There was a graded increase in the adjusted HRs for mortality according to NAE severity category: HR (95%CI), 4.02 (2.45-6.57) for intermediate-severity; and 9.85 (5.45-17.81) for serious NAEs compared to low-severity NAEs. Male sex (HR 2.04; 95% CI, 1.11-3.84), ag

Influence of the length of hospitalisation in post-discharge outcomes in patients with acute heart failure: Results of the LOHRCA study.

To investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation. Consecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH 6 days vs. LOH We included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4-11): 2934 (34.3%) had a LOH 15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0-64.9) when LOH was 11-15 days, and by 72.0% (95%CI = 42.6-107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4-36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk. Short hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments

Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study

Background Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications. Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients’ preoperative physical status, providing adjusted odds ratios (ORadj) and adjusted absolute risk reduction (ARRadj). This study is registered with ClinicalTrials.gov, number NCT01865513. Findings Between June 16, 2014, and April 29, 2015, data from 22803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21694); ORadj 1·86, 95% CI 1·53–2·26; ARRadj –4·4%, 95% CI –5·5 to –3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (ORadj 1·31, 95% CI 1·15–1·49; ARRadj –2·6%, 95% CI –3·9 to –1·4) and the administration of reversal agents (1·23, 1·07–1·41; –1·9%, –3·2 to –0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (ORadj 1·03, 95% CI 0·85–1·25; ARRadj –0·3%, 95% CI –2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82–1·31; –0·4%, –3·5 to 2·2) was associated with better pulmonary outcomes. Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications