Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Manejo de la analgesia postoperatoria en las primeras 24 horas en un Hospital de segundo nivel: Estudio observacional

Objective: We carried out this study in our second level hospital to evaluate the fulfillment and effectiveness of postoperative analgesics administered without appropriate guidelines during the first 24 h after surgical procedures where the intensity of pain is considered moderate-severe. Method: We included 119 patients above 18 years of age, who underwent orthopedic surgery: total knee or hip replacement, vertebral arthrodesis, shoulder surgery and laparotomies. Postoperative analgesics (base and rescue) were prescribed according to criterion of the responsible anesthesiologist through lack of appropriate protocols. The use of morphine, epidural analgesia and PCA (patient controlled analgesia) devices were restricted to recovery room and critical care unit. In hospitalized patients the prescribed opiates were meperidine and tramadol by intramuscular and intravenouse route, respectively. The opiates were always associated to nonsteroidal antiinflammatory drugs (NSAIDs) as metamizol or diclofenac and analgesics as paracetamol. Intensity of pain was measured by VAS 0-100 mm and verbal scale (VS) 1-4, 24 h after surgery (24) and we registered the maxim intensity of pain (Max) perceived during the first postoperative day, in both moments the percentages of patients with non controlled pain (NCP): VAS >30 and VS >2 were considered. Prescribed and administered doses of analgesic drugs (base and rescue) were registered. The proportion between prescribed and administered doses of analgesics was considered as a fulfillment indicator and expressed by percentage (GC).≠ Results: Pain intensity 24: VAS 27.8 ± 22.6, VS 2 (1-4); percentage of patients with NCP measured by VAS/VS: 36.1 and 42.8%, respectively . Max: VAS 58.4 ± 28.9, VS 4 (1-4); NCP by VAS/VS: 79.8 / 82.3 %, respectively. Prescribed opiates (Nº patients, X± SD and GC %): morphine : 28, 11.7 ± 12.6 mg /day, 100%; meperidine: 58, 333.4 ± 108.7 mg/day, 35.2%; tramadol: 13, 218.9 ± 80.2 mg/day, 59.3%. Administered NSAIDs ( Nº patients, X ± SD): diclofenac : 39, 223.1 ± 52.5 mg /day; metamizol : 74, 6.86 ± 1.8 mg /day. Conclusions: We observed medical inframetering prescription of opiates and lack of fulfillment in the administration from the infirmary staff. On the contrary NSAIDs were prescribed and administered at higher doses than the recommended ones. These results suggest that postoperative pain is not well controlled in our hospital. The continuing education and involvement of anesthesiologists, nurses and surgeons are essential factors to improve the quality of pain relief.Objetivo: Evaluar el cumplimiento y eficacia de la medicación analgésica no protocolizada y utilizada en un hospital de segundo nivel en las 24 h posteriores a cirugía, donde la intensidad del dolor está catalogada como moderada severa. Método: Estudio prospectivo y observacional. Se incluyeron 119 pacientes mayores de 18 años, intervenidos de cirugía traumatológica: prótesis total de cadera, rodilla, artrodesis vertebral, cirugía de hombro y laparotomías. Ante la falta de protocolos, la medicación analgésica postoperatoria de base y de rescate fue prescrita según criterio del anestesiólogo responsable. La administración de cloruro mórfico y el empleo de los dispositivos de administración: catéteres peridurales, PCA (analgesia controlada por el paciente) quedaron restringidos a la unidad de recuperación anestésica (URPA) y al área crítica. En planta de hospitalización los opiáceos prescritos fueron la meperidina por vía intramuscular y el tramadol endovenoso. Los opiáceos siempre se asociaron a analgésicos parenterales como metamizol, diclofenaco o paracetamol Se valoró la intensidad del dolor (VAS 0-100 mm y escala verbal EV 1-4) 24 h después de la cirugía (24) y se registró la máxima intensidad de dolor percibida en el primer día de postoperatorio (Max). Se consideró el porcentaje de pacientes con dolor no controlado (DNC): VAS >30 y EV >2 para los momentos 24 y Max. Se consignaron las dosis de fármacos analgésicos de base y rescate, prescritos y consumidos. Para cada analgésico prescrito como base, se calculó la diferencia porcentual entre la dosis media prescrita y la dosis media consumida, indicador que se denominó grado de cumplimiento (GC). Resultados: Intensidad de dolor 24: VAS 27.8 ± 22.6, EV 2; porcentaje de pacientes con DNC según VAS /EV: 36.1/ 42.8%, respectivamente. Max: VAS 58.4 ± 28.9, EV 4; DNC según VAS/EV : 79.8 / 82.3 %, respectivamente. Prescripción de opiáceos (Nº pacientes, X ± DE) y GC (%): morfina: 28, 11.7 ± 12.6 mg/día, 100%; meperidina: 58, 333.4 ± 108.7 mg/día, 35.2%; tramadol: 13, 218.9 ± 80.2 mg/día, 59.3%. Consumo de analgésicos antiinflamatorios no esteroideos (Nº pacientes, X ± DE): diclofenaco ( 39, 223.1 ± 52.5 mg/día); metamizol (74, 6.86 ± 1.8 mg/día) ambos superiores a las dosis recomendadas. Conclusiones: Como conclusión pensamos que los resultados expuestos demuestran la ineficacia de la medicación analgésica empleada en el postoperatorio, debida a fallos en la prescripción y en el cumplimiento de la misma. La formación continuada, la implicación de los anestesiólogos y del personal de enfermería y el compromiso institucional son elementos fundamentales para corregir los errores observados en el tratamiento del dolor postoperatorio

Conocimientos y actitudes de pacientes y personal sanitario frente al dolor postoperatorio

Introduction: Lack of updated knowledge about postoperative pain in health care professionals sustains suboptimal practice that Jeopardize patients' recovery. In the context of an Acute Pain Service programme, and before the development of an educational plan, a survey exploring attitudes and abilities of patients, nurses and surgeons about postoperative pain was performed. Material and methods: The study was carried out in a teaching hospital with 240 adult surgical beds. One hundred questionnaires regarding postoperative pain experiences and expectations were distributed among patients above 18 years of age undergoing elective surgical procedures. Surgical wards nurses received 100 questionnaires to investígate attitudes and knowledge toward postoperative pain treatments. Sixty five questionnaires addressed surgical staff enquired about complications and management of postoperative pain. Results: 79% (IC95%: 68-87) of patients had previously undergone surgical procedures, 39% (IC95%: 27-51) of these claimed to have experienced pain and it was modérate or severe for 46% of them. Regarding the subsequent procedure, 65% (IC95%: 54-75) of patients preferred to receive morphine before having pain. 18% (IC95%: 10-27) of nursing staff did not know about correct intramuscular opioids management, and 10% (IC95%: 4-17) were not familiar with the intravenous route. Treatment with epidural local anaesthetics was unknown for 23% (IC95%: 4-33) of nurses. 46% (IC95%: 35-57) of them believed that fear to side effeets precluded adminis-tration of opioids. Only 53% (IC95%: 40-66) of surgeons knew that postoperative pain could cause abdominal ileus. When they were required because their patient referred pain, only 33% (IC95%: 21-46) of them ordered the analgesic treatment. 100% of surgical staff preferred to follow appropriate guidelines to treat postoperative pain. Conclusions: Continuing education of health care personnel and information given to patients about postoperative pain are essential for effectiveness and safety of the analgesic treatments.Introducción: La falta de actualización del personal sanitario en el tema del dolor postoperatorio perpetúa conceptos y conductas erróneas que perjudican la recuperación de los pacientes. En el contexto de la creación de una Unidad de Dolor Agudo y previamente al desarrollo de un plan de formación, se diseñó el presente estudio para conocer el nivel de conocimientos y las actitudes de pacientes y personal sanitario en relación al dolor postoperatorio. Material y método: Estudio realizado en un hospital de 765 camas (240 quirúrgicas). Se distribuyeron 100 cuestionarios a pacientes mayores de 18 años tributarios de intervención quirúrgica programada, con preguntas referidas al dolor postoperatorio en sus antecedentes quirúrgicos y las expectativas ante la próxima operación. Se repartieron 100 cuestionarios entre enfermería de hospitalización, indagando sobre el conocimiento de diferentes técnicas analgésicas y actitudes respecto al manejo de opiáceos. El personal médico quirúrgico que recibió 65 cuestionarios fue consultado acerca de las complicaciones y tratamiento del dolor postoperatorio. Resultados: El 79% (IC 95%: 68-87) de los pacientes entrevistados había sido operado anteriormente. El 39% (IC 95%: 27-51) de los mismos recordaba haber sentido dolor en el postoperatorio y de ellos el 46 % catalogaba al dolor como moderado - intenso. En relación a la futura intervención quirúrgica, el 65% (IC 95%:54-75) prefería que se le administrase morfina antes de padecer dolor. En el ámbito de la enfermería, el 18% (IC 95%: 10-27) y el 10% (IC 95%: 4-17) del personal desconocía el manejo de opiáceos por vía intramuscular y vía intravenosa respectivamente. El tratamiento del dolor con anestésicos locales por vía peridural era desconocido para el 23% (IC 95%: 4-33). Para el 46% (IC 95%:35-57) de la enfermería encuestada, el temor a los efectos indeseables de los mórficos, condicionaba su administración. Sólo el 53% (IC 95%: 40-66) de los cirujanos sabía que el dolor postoperatorio podía ser causa del retraso de la motilidad gastrointestinal. Ante la conducta que adoptaban los médicos cuando eran requeridos porque un paciente refería dolor postoperatorio, sólo el 33% (IC 95%: 21-46) prescribía los analgésicos. El 100% de los facultativos prefería seguir protocolos diseñados para el tratamiento del dolor postoperatorio. Conclusiones: La educación continuada del personal sanitario y la información entregada a los pacientes en el ámbito del dolor postoperatorio son fundamentales para el tratamiento efectivo y seguro de los pacientes operados

Granuloma en la incisión tras el implante de un estimulador eléctrico medular

Presentamos el caso de un paciente que sufrió como complicación de la estimulación eléctrica medular, implantado a causa de su dolor neuropático, un granuloma en la incisión lumbar, a nivel de la conexión intermedia. Este granuloma evolucionó pese a su correcto diagnóstico y tratamiento precoz, a una infección de tejidos profundos con migración de los electrodos, por lo que precisó la retirada de éstos.It is showed you a patient who presented a granuloma in the lumbar incision at the level of the intermediate connection as a complication of the spinal cord stimulation, due to his neuropathic pain. This granuloma developed a deep tissue infection with migration of the electrodes despite right diagnostic and early treatment. Removal of the electrodes was finally required

Recomendaciones de prevención y tratamiento de las náuseas y vómitos postoperatorios y/o asociados a las infusiones de opioides

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Española de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.Las náuseas y los vómitos postoperatorios (NVPO) producen malestar e insatisfacción del paciente y aumentan la necesidad de cuidados. La infusión de opiáceos, frecuente como tratamiento analgésico postoperatorio, puede inducir náuseas y/o vómitos (NV). Este trabajo tiene como objetivo el desarrollo de recomendaciones de prevención y tratamiento de ambos problemas. Con este fin se constituyó un Grupo de Trabajo de acuerdo con los estatutos de la Sociedad Española de Anestesiología y Reanimación. Dicho grupo realizó una evaluación crítica de artículos relevantes sobre el manejo de las NV perioperatorios precoces y tardíos tanto en adultos como en niños. Tras varias reuniones y discusión se acordaron las siguientes recomendaciones (resumen): 1. Todos los pacientes sometidos a cirugía deben ser evaluados respecto al riesgo de desarrollar NVPO. Se recomiendan las escalas de Apfel et al. para adultos y de Eberhart et al. para niños, ambas son útiles y fáciles de aplicar; 2. En los adultos con riesgo moderado o alto y en todos los niños se deben adoptar medidas de reducción del riesgo basal; 3. La profilaxis con un fármaco es útil en pacientes de riesgo bajo (Apfel 1 o Eberhart 1) sometidos a anestesia general. En los demás pacientes se debe realizar profilaxis con 2 o más fármacos y reducir el riesgo basal (abordaje multimodal); 4. Dexametasona, droperidol y ondansetrón (setrones en general) tienen similar eficacia. La elección de fármaco debe tener en consideración factores individuales en cada paciente; 5. El tratamiento de las NVPO establecidas debe hacerse preferentemente con un fármaco diferente al empleado en la profilaxis. El fármaco más efectivo es el ondansetrón; 6. Debe evaluarse la posibilidad de NVPO tras el alta del paciente en cirugía ambulatoria o en la sala de hospitalización en cirugía con ingreso. No existen evidencias suficientes para formular una estrategia de prevención de las NV tardíos; 7. El fármaco de elección en la prevención de las NV asociadas a infusión de opiáceos es droperidol

Axillary local anesthetic spread after the thoracic interfacial ultrasound block – a cadaveric and radiological evaluation

Background: Oral opioid analgesics have been used for management of peri- and postoperative analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block and does not have a specific regional anesthesia technique published that offers its adequate blockade. Methods: After institutional review board approval, anatomic and radiological studies were conducted to determine the deposition and spread of methylene blue and local anesthetic injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy, or supernumerary breasts, to ascertain the deposition and time course of spread of solution within the thoracic interfascial plane in vivo. Results: Radiological and cadaveric studies showed that the injection of local anesthetic and methylene blue via the thoracic inter-fascial plane, using ultrasound guide technique, results in reliable deposition into the axilla. In patients, the injection of the local anesthetic produced a reliable axillary sensory block. This finding was supported by Magnetic Resonance Imaging studies that showed hyper-intense signals in the axillary region. Conclusions: These findings define the anatomic characteristics of the thoracic interfascial plane nerve block in the axillary region, and underline the clinical potential of this novel nerve block. Resumo: Justificativa: Os analgésicos orais à base de opioides têm sido usados para o manejo da analgesia nos períodos peri e pós-operatório de pacientes submetidos à linfadenectomia axilar. A região axilar é uma zona difícil de bloquear e não há registro de uma técnica de anestesia regional específica que ofereça o seu bloqueio adequado. Métodos: Após a aprovação do Conselho de Ética institucional, estudos anatômicos e radiológicos foram realizados para determinar a deposição e disseminação de azul de metileno e anestésico local, respectivamente injetados na axila via plano interfascial torácico. Exames de ressonância magnética foram então realizados em 15 de 34 pacientes programados para cirurgia de mama unilateral envolvendo qualquer um dos seguintes procedimentos: esvaziamento axilar, biópsia de linfonodo sentinela, biópsia de linfonodo axilar, ou mamas supranumerárias, para verificar a deposição e tempo de propagação da solução dentro do plano interfascial torácico in vivo. Resultados: Estudos radiológicos e em cadáveres mostraram que a injeção de anestésico local e azul de metileno via plano interfascial torácico usando a técnica guiada por ultrassom resulta em deposição confiável na axila. Nos pacientes, a injeção de anestésico local produziu um bloqueio sensitivo axilar confiável. Esse achado foi corroborado por estudos de ressonância magnética que mostraram sinais hiperintensos na região axilar. Conclusões: Esses achados definem as características anatômicas do bloqueio da região axilar e destacam o potencial clínico desses novos bloqueios. Keywords: Anesthesia, conduction, Axilla, Intercostal muscles, Brachial plexus block, Intercostal nerves, Lymph node excision, Ultrasonography, Palavras-chave: Anestesia por condução, Axila, Músculos intercostais, Bloqueio do plexo braquial, Nervos intercostais, Excisão de linfonodo, Ultrassonografi

Axillary local anesthetic spread after the thoracic interfacial ultrasound block - a cadaveric and radiological evaluation

Abstract Background Oral opioid analgesics have been used for management of peri- and postoperative analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block and does not have a specific regional anesthesia technique published that offers its adequate blockade. Methods After institutional review board approval, anatomic and radiological studies were conducted to determine the deposition and spread of methylene blue and local anesthetic injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy, or supernumerary breasts, to ascertain the deposition and time course of spread of solution within the thoracic interfascial plane in vivo. Results Radiological and cadaveric studies showed that the injection of local anesthetic and methylene blue via the thoracic inter-fascial plane, using ultrasound guide technique, results in reliable deposition into the axilla. In patients, the injection of the local anesthetic produced a reliable axillary sensory block. This finding was supported by Magnetic Resonance Imaging studies that showed hyper-intense signals in the axillary region. Conclusions These findings define the anatomic characteristics of the thoracic interfascial plane nerve block in the axillary region, and underline the clinical potential of this novel nerve block