Docencia de la Medicina Intensiva. Aspectos bioéticos

Cualquier acto médico presenta siempre una doble vertiente, técnica y moral. La bioética, surge como herramienta clave para poder conjugar ambos aspectos en la toma diaria de decisiones médicas. Además, docencia y aprendizaje estarán presentes de forma patente durante toda la vida profesional de la mayoría de los médicos. En la actualidad, los avances obtenidos por la comunidad universitaria en cuanto a la docencia de la bioética son notables. No han sido tan claro, sin embargo, para la formación durante la residencia ni tras la especialidad. El contexto de la Medicina Intensiva, dedicada a pacientes con enfermedades críticas, ofrece una serie de particularidades que pueden ser beneficiosas para el aprendizaje de muchos aspectos bioéticos. Estos incluyen, entre otros, el respeto a la autonomía del paciente, la búsqueda de la beneficencia, incluso durante los cuidados al final de la vida, o la toma de decisiones en equipo o en situaciones de extrema urgencia. En cuanto al modo de enseñanza de la bioética existen diferentes aproximaciones, desde la clásica clase magistral a la clase invertida o el método del caso, que tiene su mayor exponente en la simulación. Nuestra propuesta particular consiste en la integración de la práctica y la discusión en grupo como elemento fundamental de la enseñanza de la bioética, ayudada de las metodologías más recientes, fundamentalmente, de la simulación. Cualquier acto médico presenta siempre una doble vertiente, técnica y moral. La bioética, surge como herramienta clave para poder conjugar ambos aspectos en la toma diaria de decisiones médicas. Además, docencia y aprendizaje estarán presentes de forma patente durante toda la vida profesional de la mayoría de los médicos. En la actualidad, los avances obtenidos por la comunidad universitaria en cuanto a la docencia de la bioética son notables. No han sido tan claro, sin embargo, para la formación durante la residencia ni tras la especialidad.El contexto de la Medicina Intensiva, dedicada a pacientes con enfermedades críticas, ofrece una serie de particularidades que pueden ser beneficiosas para el aprendizaje de muchos aspectos bioéticos. Estos incluyen, entre otros, el respeto a la autonomía del paciente, la búsqueda de la beneficencia, incluso durante los cuidados al final de la vida, o la toma de decisiones en equipo o en situaciones de extrema urgencia.En cuanto al modo de enseñanza de la bioética existen diferentes aproximaciones, desde la clásica clase magistral a la clase invertida o el método del caso, que tiene su mayor exponente en la simulación. Nuestra propuesta particular consiste en la integración de la práctica y la discusión en grupo como elemento fundamental de la enseñanza de la bioética, ayudada de las metodologías más recientes, fundamentalmente, de la simulación

De-RISC: A complete RISC-V based space-grade platform

The H2020 EIC-FTI De-RISC project develops a RISC-V space-grade platform to jointly respond to several emerging, as well as longstanding needs in the space domain such as: (1) higher performance than that of monocore and basic multicore space-grade processors in the market; (2) access to an increasingly rich software ecosystem rather than sticking to the slowly fading SPARC and PowerPC-based ones; (3) freedom (or drastic reduction) of export and license restrictions imposed by commercial ISAs such as Arm; and (4) improved support for the design and validation of safety-related real-time applications, (5) being the platform with software qualified and hardware designed per established space industry standards. De-RISC partners have set up the different layers of the platform during the first phases of the project. However, they have recently boosted integration and assessment activities. This paper introduces the De-RISC space platform, presents recent progress such as enabling virtualization and software qualification, new MPSoC features, and use case deployment and evaluation, including a comparison against other commercial platforms. Finally, this paper introduces the ongoing activities that will lead to the hardware and fully qualified software platform at TRL8 on FPGA by September 2022.This project has received funding from the European Union’s Horizon 2020 Research and Innovation programme under Grant Agreement EIC-FTI 869945. BSC work has also been partially supported by the Spanish Ministry of Science and Innovation under grant PID2019-07255GBC21/AEI/10.13039/501100011033.Peer ReviewedPostprint (author's final draft

Clinical presentation of acute coronary syndrome in patients previously treated with nitrates

Aims: Several reports have suggested that nitrates limit acute ischaemic damage by a mechanism similar to preconditioning. This study aims to evaluate the effect of chronic oral nitrates on the clinical presentation and short-term outcomes of patients admitted with acute coronary syndrome (ACS).Methods: A retrospective cohort study was conducted in patients with ACS admitted to 62 acute care units from 2010 to 2011. A propensity score-matched samples analysis was performed.Results: We analysed 3171 consecutive patients, of whom 298 (9.4%) were chronically treated with nitrates. Patients previously treated with nitrates had higher comorbidity and disease severity at admission, lower prevalence of ACS with ST elevation, lower troponin elevation, higher prevalence of initial Killip class 2-4 and higher hospital mortality. The propensity score-matched analysis confirmed that previous use of nitrates is independently associated with a lower prevalence of ST-elevation ACS [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.36-0.78; P = 0.0014] and a lower troponin elevation (OR 0.61, 95% CI 0.41-0.92) but not with Killip class on admission (OR 1.18, 95% CI 0.83-1.67, P = 0.3697) or mortality (OR 0.71, 95% CI 0.37-1.38, P = 0.3196).Conclusion: The results support the hypothesis that nitrates have a protective effect on acute ischaemic injury

Estrategia invasiva de rutina en el síndrome coronario agudo sin elevación del segmento ST con disfunción renal. Resultados del registro ARIAM-SEMICYUC

Objetivo: Evaluar la utilización y efectividad de la estrategia invasiva de rutina (EIR) en pacientes con síndrome coronario agudo sin elevación de ST con disfunción renal en el mundo real. Métodos: Estudio de cohortes retrospectivo basado en el registro ARIAM-SEMICYUC (años 2011- 2014). Se consideró que había disfunción renal cuando el GFR (Cockroft-Gault) era menor de 60 ml/min (disfunción moderada) o de 30 ml/min (disfunción grave). Se excluyeron los pacientes en los que la coronariografía precoz (< 72 h) se debió a shock cardiogénico o isquemia recurrente. El desenlace primario fue la mortalidad hospitalaria. El control del confounding se realizó mediante un análisis de propensión. Resultados: Se analizan 4.279 pacientes, de los cuales un 26% tenía disfunción renal moderada y un 5% disfunción grave. Los pacientes con disfunción renal presentaron una mayor gravedad y comorbilidad, una mayor mortalidad hospitalaria (8,6 frente a 1,8%) y una menor utilización de la EIR (40 frente a 52%). Las OR ajustadas mediante emparejamiento para pacientes sin/con disfunción renal fueron de 0,38 (intervalo de confianza al 95% [IC95%] de 0,17 a 0,81) y 0,52 (IC95% de 0,32 a 0,87), respectivamente (p de interacción 0,4779). El impacto de la EIR (diferencia de riesgos ajustada) fue mayor en el grupo con disfunción renal (−5,1%, IC95% entre −8,1 y −2,1, frente a −1,6%, IC95% entre −2,6 y −0,6, p de interacción = 0,0335). Tampoco se detectó interacción significativa respecto a los demás enlaces considerados (mortalidad en UCI o a los 30 días, riesgo combinado de muerte o infarto, fracaso renal agudo o hemorragias moderadas/graves). Conclusiones: Los resultados evidencian que la efectividad de la EIR es similar en pacientes con función renal normal o reducida y alertan sobre una infrautilización de esta estrategia en estos últimos.Objective: To evaluate the use and effectiveness of a routine invasive strategy (RIS) in patients with acute coronary syndrome without persistent ST-segment elevation with renal dysfunction in the real world scenario. Methods: A retrospective cohort study based on the ARIAM-SEMICYUC Registry (2011-2014) was carried out. Renal dysfunction was defined as GFR (Cockroft-Gault)<60ml/min (moderate dysfunction) or<30ml/min (severe dysfunction). Patients in which early angiography (<72h) was performed due to cardiogenic shock or recurrent myocardial ischemia were excluded. The primary endpoint was hospital mortality. Confounding factors were controlled using propensity score analysis. Results: A total of 4,279 patients were analyzed, of which 26% had moderate renal dysfunction and 5% severe dysfunction. Patients with renal dysfunction had greater severity and comorbidity, higher hospital mortality (8.6 vs. 1.8%), and lesser use of the RIS (40 vs. 52%). The adjusted OR for mortality in patients without/with renal dysfunction were 0.38 (95% confidence interval [95%CI] 0.17 to 0.81) and 0.52 (95%CI 0.32 to 0.87), respectively (interaction P-value=.4779). The impact (adjusted risk difference) of RIS was higher in the group with renal dysfunction (-5.1%, 95%CI -8.1 to -2.1 vs. -1.6%, 95%CI -2.6 to -0.6; interaction P-value=.0335). No significant interaction was detected for the other endpoints considered (ICU mortality, 30-day mortality, myocardial infarction, acute renal failure or moderate/severe bleeding).Conclusions: The results suggest that the effectiveness of IRS is similar in patients with normal or abnormal renal function, and alert to the under-utilization of this strategy in such patients

MARIBNO project: Structure of the NorthWest Iberian margin: influence of inherited tectonics in the Alpine extension and inversion

X Congreso Geológico de España, 5-7 Julio 2021, Vitoria - GasteizLa zona noroeste de Iberia reúne rasgos geológicos excepcionales relacionados con el desarrollo de un margen continental hiperextendido cerca de un punto triple y la posterior inversión tectónica parcial. Es una zona de gran interés para el estudio del papel de la herencia tectónica y la posterior inversión en márgenes continentales extensionales, pero hay un gran déficit de información. Todo esto sienta las bases del proyecto anfibio MARIBNO (PGC2018-095999-B-I00) donde a lo largo de 2021 y 2022 se adquirirán sísmica marina de reflexión multicanal 2D (~4000 km), sísmica de gran ángulo en 3 transectos tierra-mar (~600 km), batimetría multihaz, grav-mag y sísmica de alta resolución. Se complementará en tierra con adquisición de datos grav-mag y varias campañas de cartografía geológica. Los objetivos se centran en el estudio de la estructura cortical, el control tectónico ejercido por estructuras previas a las etapas alpinas y la cartografía y caracterización de los dominios corticales aunando criterios geológicos y geofísicos.Todo esto sienta las bases del proyecto anfibio MARIBNO (PGC2018-095999-B-I00) donde a lo largo de 2021 y 2022 se adquirirán sísmica marina de reflexión multicanal 2D (~4000 km), sísmica de gran ángulo en 3 transectos tierra-mar (~600 km), batimetría multihaz, grav-mag y sísmica de alta resolución

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Differential clinical characteristics and prognosis of intraventricular conduction defects in patients with chronic heart failure

Intraventricular conduction defects (IVCDs) can impair prognosis of heart failure (HF), but their specific impact is not well established. This study aimed to analyse the clinical profile and outcomes of HF patients with LBBB, right bundle branch block (RBBB), left anterior fascicular block (LAFB), and no IVCDs. Clinical variables and outcomes after a median follow-up of 21 months were analysed in 1762 patients with chronic HF and LBBB (n = 532), RBBB (n = 134), LAFB (n = 154), and no IVCDs (n = 942). LBBB was associated with more marked LV dilation, depressed LVEF, and mitral valve regurgitation. Patients with RBBB presented overt signs of congestive HF and depressed right ventricular motion. The LAFB group presented intermediate clinical characteristics, and patients with no IVCDs were more often women with less enlarged left ventricles and less depressed LVEF. Death occurred in 332 patients (interannual mortality = 10.8%): cardiovascular in 257, extravascular in 61, and of unknown origin in 14 patients. Cardiac death occurred in 230 (pump failure in 171 and sudden death in 59). An adjusted Cox model showed higher risk of cardiac death and pump failure death in the LBBB and RBBB than in the LAFB and the no IVCD groups. LBBB and RBBB are associated with different clinical profiles and both are independent predictors of increased risk of cardiac death in patients with HF. A more favourable prognosis was observed in patients with LAFB and in those free of IVCDs. Further research in HF patients with RBBB is warranted

Dietary α‐Linolenic Acid, Marine ω‐3 Fatty Acids, and Mortality in a Population With High Fish Consumption: Findings From the PREvención con DIeta MEDiterránea (PREDIMED) Study

Background: Epidemiological evidence suggests a cardioprotective role of α‐linolenic acid (ALA), a plant‐derived ω‐3 fatty acid. It is unclear whether ALA is beneficial in a background of high marine ω‐3 fatty acids (long‐chain n‐3 polyunsaturated fatty acids) intake. In persons at high cardiovascular risk from Spain, a country in which fish consumption is customarily high, we investigated whether meeting the International Society for the Study of Fatty Acids and Lipids recommendation for dietary ALA (0.7% of total energy) at baseline was related to all‐cause and cardiovascular disease mortality. We also examined the effect of meeting the society's recommendation for long‐chain n‐3 polyunsaturated fatty acids (≥500 mg/day). Methods and Results: We longitudinally evaluated 7202 participants in the PREvención con DIeta MEDiterránea (PREDIMED) trial. Multivariable‐adjusted Cox regression models were fitted to estimate hazard ratios. ALA intake correlated to walnut consumption (r=0.94). During a 5.9‐y follow‐up, 431 deaths occurred (104 cardiovascular disease, 55 coronary heart disease, 32 sudden cardiac death, 25 stroke). The hazard ratios for meeting ALA recommendation (n=1615, 22.4%) were 0.72 (95% CI 0.56–0.92) for all‐cause mortality and 0.95 (95% CI 0.58–1.57) for fatal cardiovascular disease. The hazard ratios for meeting the recommendation for long‐chain n‐3 polyunsaturated fatty acids (n=5452, 75.7%) were 0.84 (95% CI 0.67–1.05) for all‐cause mortality, 0.61 (95% CI 0.39–0.96) for fatal cardiovascular disease, 0.54 (95% CI 0.29–0.99) for fatal coronary heart disease, and 0.49 (95% CI 0.22–1.01) for sudden cardiac death. The highest reduction in all‐cause mortality occurred in participants meeting both recommendations (hazard ratio 0.63 [95% CI 0.45–0.87]). Conclusions: In participants without prior cardiovascular disease and high fish consumption, dietary ALA, supplied mainly by walnuts and olive oil, relates inversely to all‐cause mortality, whereas protection from cardiac mortality is limited to fish‐derived long‐chain n‐3 polyunsaturated fatty acids. Clinical Trial Registration URL: http://www.Controlled-trials.com/. Unique identifier: ISRCTN35739639

Estudio del patrón hormonal precoz, hipofisario anterior y tiroideo en el paciente traumatizado

Tesis doctoral inédita leída el 16 de Marzo de 1999 en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Cirugí

Postoperative management in the Intensive Care Unit of head and neck surgery patients

El cuidado del paciente tras cirugía mayor de cabeza y cuello ha cambiado en los últimos años. La patología que acapara este tipo de intervenciones es la tumoral; aunque también se utiliza para resolución de patologías benignas. Recientes avances en el equipamiento y en las técnicas quirúrgicas han mejorado el postoperatorio en este campo, permitiendo una recuperación precoz, un menor grado de dolor y tasa de infección, una menor estancia hospitalaria e incluso unos mejores resultados estéticos. Esto se debe al uso de técnicas mínimamente invasivas, que están cobrando protagonismo en los últimos años. Estas permiten realizar procedimientos complejos en la región de cabeza y cuello, a través de orificios naturales o pequeñas incisiones, con mínimo daño y mínimas secuelas para los pacientes. A pesar de estos avances, dada la complejidad de la intervención, el manejo de estos pacientes requerirá un enfoque multidisciplinar, fundamentalmente en las unidades de cuidados intensivos para vigilar la posible aparición de complicaciones. Entre los factores de riesgo potenciales destacan: comorbilidad previa, el tipo de intervención, como el vaciamiento cervical bilateral, la necesidad de politransfusión y la aparición de complicaciones precoces que requieren una reintervención. A pesar de diversos estudios realizados, no existen protocolos estandarizados para el período postoperatorio de este tipo de intervenciones, lo que hace que muchos trasladen protocolos de recuperación precoz (ERAS: «Enhanced Recovery After Surgery») ya instaurados en otras especialidades quirúrgicas.Patient care after major head and neck surgery has changed in recent years. Tumors are the most common reasons for this type of surgery, though it is also used to treat benign conditions. Recent advances in equipment and surgical techniques have improved the postoperative course in this field, allowing early recovery, less pain and infection, a shorter hospital stay, and even better aesthetic results. This is due to the use of minimally invasive techniques, which are gaining relevance. Such techniques allow complex procedures in the head and neck region, through natural orifices or small incisions, with minimal damage and sequelae for the patients. Despite these advances, however, the complexity of the treatment intervention requires multidisciplinary patient management, mostly in the Intensive Care Unit, in order to monitor the possible occurrence of complications. Potential risk factors include previous comorbidity, the type of surgery involved (e.g., bilateral cervical lymphadenectomy), multiple transfusions, and the appearance of early complications requiring repeat surgery. Despite the existence of several studies, there are no standardized protocols for the postoperative period in surgeries of this kind. This causes many specialists to resort to accelerated recovery protocols (ERAS: “Enhanced Recovery After Surgery”) that have already been established in other surgical specialties.Sin financiación2.491 JCR (2020) Q3, 26/36 Critical Care Medicine0.336 JCR (2020) Q3, 46/88 Critical Care and Intensive Care MedicineNo data IDR 2020UE