Predicción de mortalidad en cirugía cardíaca mediante la combinación del tiempo de circulación extracorpórea, procalcitonina sérica y EuroSCORE

El objetivo principal de nuestro estudio es demostrar y validar un modelo de predicción de mortalidad en pacientes intervenidos de cirugía cardíaca, elaborado a partir de la inclusión de factores intraoperatorios y de parámetros de inflamación a la escala de riesgo EuroSCORE estándar. Como objetivo secundario describiremos la capacidad de la escala EuroSCORE estándar para predecir complicaciones en el postoperatorio de cirugía cardíaca. Se diseño un estudio prospectivo, observacional de cohortes con 1605 pacientes intervenidos de cirugía cardíaca con CEC. Se elaboró un modelo de predicción de mortalidad que incluía las variables EuroSCORE, tiempo de CEC y concentración de PCT a las 24 horas. El nuevo modelo demostró tener una buena capacidad para predecir mortalidad [ABC = 0,89 (IC 95%: 0,85 - 0,95)] , superando al modelo EuroSCORE [ABC =0,82 (IC 95%: 0,75 - 0,89)]. Los resultados se confirmaron en la cohorte de validación. La escala EuroSCORE estándar también demostró tener una buena capacidad para predecir estancias prolongadas en la Unidad de Reanimación, fallo renal, el empleo de técnicas de reemplazo renal, fallo respiratorio, la parada cardíaca y el shock séptico.Departamento de Cirugía, Oftalmología, Otorrinolaringología y FisioterapiaDoctorado en Investigación en Ciencias de la Salu

Manejo del Síndrome de Distrés Respiratorio Agudo (SDRA). ¿Qué hay de nuevo?

Acute respiratory distress syndrome (ARDS) it is an acute and diffuse lung disease. The consequences are hypoxemia, decreased lung compliance and increased intrapulmonary shunt and dead space.There are different opinions about the treatment of this disease. It is necessary to have clinical practice guidelines where treatment strategies are organized according to the best scientific evidence. Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome are proposed in these guidelines.El síndrome de Distrés respiratorio es una enfermedad pulmonar aguda y difusa que produce hipoxemia, disminución de la compliance pulmonar y aumento del espacio muerto. Existe disparidad de opiniones sobre el manejo de esta patología, por lo que es necesario disponer de guías de práctica clínica  donde se organicen las estrategias de tratamiento de acuerdo a la mejor evidencia científica. En esta guía se proponen quince recomendaciones y un algoritmo terapéutico sobre el manejo del síndrome de Distrés respiratorio agudo.    

Reflexionemos como comunidad profesional docente sobre la naturaleza del aprendizaje en temas de biología de la educación básica

In this workshop, participants, as a community of teaching professionals, will analyze on the nature of school learning. The analysis arises from the perception evoked by the participants around the actions carried out by three teachers of the preschool, primary and secondary educational levels, who perform some teaching sequence in biology subjects. The classes that are to be watch are videotaped and based on them, a record of the class dynamics will be made. Finally, based upon some frameworks the community will reach a consensus and some criteria points will be proposed for new observations and collaboration for new analyzes. The above with the purpose of providing elements of discussion and analysis around of what our teachers expect their basic education students to learn in science classes when biology issues are addressed.En este taller los participantes, como una comunidad de profesionales docentes, reflexionaran sobre la naturaleza del aprendizaje escolar. La reflexión surge de la percepción evocada por los participantes alrededor de las acciones realizadas por tres docentes de los niveles educativos preescolar, primaria y secundaria, quienes realizan alguna secuencia de enseñanza en temas de biología. Las clases a observar están videograbadas y con base en ellas, se realizarán registros de la dinámica de la clase. Finalmente, a partir de algunos referentes se concretarán las reflexiones en comunidad y se propondrán algunos puntos de partida para nuevas observaciones y colaboración para nuevos análisis. Lo anterior con el propósito de aportar elementos de discusión y análisis en torno al que esperamos los profesores que aprendan nuestros alumnos de educación básica en las clases de ciencias cuando se abordan temas de biología

Relación existente entre Ecocardiografía y Variables Hemodinámicas en una Unidad de Cuidados Intensivos (UCI) Cardiotorácicos

Left ventricular dysfunction and subsequent cardiovascular instability is one of the main causes of morbidity and mortality in patients admitted to ICUs. Hemodynamic monitoring allows information on cardiovascular status to be obtained, helping us to obtain an adequate diagnosis and to guide the therapy of patients admitted to these units. In this study, the authors intended to demonstrate the existence of an association between hemodynamic and echocardiographic parameters for hemodynamic evaluation in patients admitted to the ICU.La disfunción del ventrículo izquierdo y la inestabilidad cardiovascular subsiguiente es una de las principales causas de morbimortalidad en los pacientes ingresados en las UCI. La monitorización hemodinámica permite obtener información sobre el estado cardiovascular ayudándonos a obtener un diagnostico adecuado y a guiar la terapia de los pacientes ingresados en dichas unidades.  En este estudio los autores pretendían demostrar la existencia de una asociación entre parámetros hemodinámicos y los ecocardiográficos para la evaluación hemodinámica en los pacientes ingresados en UCI

Epidural analgesia and its implications in the maternal health in a low parity comunity

Producción CientíficaBackground: In regard to obstetrical analgesia management there are different results related to the use of epidural analgesia versus mechanical adverse outcomes at delivery. Methods: Cohort study of 23,183 consecutive, term, singleton vaginal deliveries, including spontaneous and induced labours, at a single institution from January 2004 to June 2016 to determine the association between epidural analgesia and different mechanical complications affecting maternal health such as severe perineal tears (SPT), abnormal foetal head position at delivery, instrumental delivery and caesarean section (CS). Multivariate logistic regression models were constructed to evaluate the risk factors of these mechanical complications with respect to possible cofounders. Results: Epidural analgesia was used in 15,821 (68.24%) women. The logistic regression model showed a non-significant association between the use of epidural analgesia and SPT (odds ratio [OR], 078; 95% confidence interval [CI], 0.48–1.26; p = 0.310). Instrumental delivery and CSs were more frequently performed in cases than controls (p = < 0.001), with OR of 1.19 (95% CI: 1.10–1.29) for CS and with OR of 3.27 (95% CI: 2.93–4.61) for instrumental delivery. The abnormal foetal position head at delivery were significantly lower in the neonates delivered without epidural analgesia compared with those in which epidural analgesia was used (p < 0.001) with OR of 1.43 (95% CI:1.27–1.72). Conclusions: Epidural analgesia is not associated with an increase of SPT, but it was an independent risk factor for instrumental delivery, CS and abnormal foetal head position at delivery

Procalcitonin and white blood cells, combined predictors of infection in cardiac surgery patients

Producción CientíficaBackground: Sepsis is strongly associated with an increased risk of postoperative mortality, longer length of hospital stay, and elevated health care costs. Early clinical symptoms overlap with those of systemic inflammatory response syndrome, a response that commonly occurs after cardiac surgery with cardiopulmonary bypass. Since a combination of biomarkers has been demonstrated to improve the prediction of postoperative infection, the objective of the present study was to test whether the combination of C-reactive protein (CRP), white blood cells (WBC), and procalcitonin (PCT) is able to predict postoperative infection in a large cohort of cardiac surgery patients. Material and methods: Case-control study involving 423 patients who underwent cardiac surgery with cardiopulmonary bypass. Patients were retrospectively classified into two groups based on whether they developed severe sepsis or septic shock during the postoperative period. Blood samples for biological measurements (PCT, CRP, and WBC) were drawn on the first day in the intensive care unit, then once daily in the morning until the 10th postoperative day. Results: CRP median values were similar in both groups. WBC and PCT median values were significantly higher in patients with infection than without during the first 10 postoperative days. With elevation cutoffs ≤3 times (OR: 4.058; 95% CI: 2.206-7.463; P = 0.001) and ≥4 times (OR: 10.274, 95% CI: 3.690-28.604; P < 0.001), the median value for PCT (1.7 ng/mL) and/or WBC (13,000 cells/mm3) on the second postoperative day was significantly associated with the development of infection. Conclusions: The goal of this study was to use a large cohort of cardiac surgery patients to ensure that the results were representative of this population. The combination of PCT and WBC levels over the first three postoperative days was able to predict postoperative infection within the 30 d following cardiac surgery.Instituto de Salud Carlos III (grant PI15/01451)Junta de Castilla y León (grant GRS1270/A/16

Predicting cardiac surgery–associated acute kidney injury: The CRATE score

Producción CientíficaPurpose: Acute kidney injury (AKI) is a frequent complication after cardiac surgery and is associated with increased mortality. The aim was to design a nondialytic AKI score in patients with previously normal renal function undergoing cardiac surgery. Methods: Data were collected on 909 patients who underwent cardiac surgery with cardiopulmonary bypass between 2012 and 2014. A total of 810 patients fulfilled the inclusion criteria. Patients were classified as having AKI based on the RIFLE criteria. Postoperative AKI occurred in 137 patients (16.9%). Several parameters were recorded preoperatively, intraoperatively, and at intensive care unit admission, looking for a univariate andmultivariate associationwith AKI risk. A second data set of 741 patients, from2 different hospitals,was recorded as a validation cohort. Results: Four independent risk factors were included in the CRATE score: creatinine (odds ratio [OR], 9.66; 95% confidence interval [CI], 4.77-19.56; P b .001), EuroSCORE (OR, 1.40; CI, 1.29-1.52; P b .001), lactate (OR, 1.03; CI, 1.01- 1.04; P b .001), and cardiopulmonary bypass time (OR, 1.01; CI, 1.01-1.02; P b .001). The accuracy of the model was good, with an area under the curve of 0.89 (CI, 0.85-0.92). The CRATE score retained good discrimination in validation cohort, with an area under the curve of 0.81 (95% CI, 0.78-0.85). Conclusions: CRATE score is an accurate and easy to calculate risk score that uses affordable andwidely available variables in the routine care surgical patients

Impact of ventilator-associated pneumonia on mortality and epidemiological features of patients with secondary peritonitis

Producción CientíficaBackground: Despite the significant impact of nosocomial infections on the morbidity and mortality of patients staying in the intensive care unit (ICU), no study over the past 20 years has focused specifically on VAP following secondary peritonitis. The objective of the present study was to determine in-hospital mortality and epidemiological features attributed to ventilator-associated pneumonia (VAP) following secondary peritonitis. Methods: Prospective observational study involved 418 consecutive patients admitted in the ICU. Univariate and multivariate analyses were performed to identify risk factors associated with mortality and development of VAP. Results: The incidence of VAP following secondary peritonitis was 9.6 %. Risk factors associated with the development of VAP were hospital-acquired peritonitis, requiring >48 h of mechanical ventilation, and SOFA score. The onset of VAP was late in majority of patients. VAP was developed about 16.8 days after the initiation of the peritonitis. Etiological microorganisms responsible for the peritonitis were different than for VAP. The 90-day in-hospital mortality rate was 47.5 % of VAP patients. Independent factors associated with 30- to 90-day in-hospital mortality were VAP and SOFA. Conclusions: In light of the impact on morbidity and mortality in the ICU, more attention should be given to the concurrent features among VAP and secondary peritonitis.Junta de Castilla y León (grant (GRS773/A/13)Instituto de Salud Carlos III (grant PI15/01451

Quantitative proteomics in medication-related osteonecrosis of the jaw: a proof-of-concept study

Objective: Medication-related osteonecrosis of the jaw (MRONJ) is a paradoxical effect associated with bone-modifying agents (BMAs) and other drugs. Currently, no valuable diagnostic or prognosis biomarkers exist. The goal of this research was to study MRONJ-related salivary proteome. Materials and Methods: This case–control aimed to study salivary proteome in MRONJ versus control groups (i) formed from BMAs consumers and (ii) healthy individuals to unravel biomarkers. Thirty-eight samples of unstimulated whole saliva (18 MRONJ patients, 10 BMA consumers, and 10 healthy controls) were collected. Proteomic analysis by SWATH-MS coupled with bioinformatics analysis was executed. Results A total of 586 proteins were identified, 175 proteins showed significant differences among MRONJ versus controls. SWATH-MS revealed differentially expressed proteins among three groups, which have never been isolated. These proteins had distinct roles including cell envelope organization, positive regulation of vesicle fusion, positive regulation of receptor binding, or regulation of low-density lipoprotein particle clearance. Integrative analysis prioritized 3 proteins (MMP9, AACT, and HBD). Under receiver-operating characteristic analysis, this panel discriminated MRONJ with a sensitivity of 90% and a specificity of 78.9%. Conclusion: These findings may inform a novel biomarker panel for MRONJ prediction or diagnosis. Nonetheless, further research is needed to validate this panelS

La naturaleza del aprendizaje en la práctica docente desde una comunidad de desarrollo profesional docente: un caso de análisis en torno a una clase para la clasificación de los seres vivos

There are a significant number of investigations, nationally and internationally, that address the phenomenon of Teaching Practice and teacher training. However, most of these address the reflection, analysis and discussion on teaching practice (TP), from generalist perspectives, that is, from pedagogy in general and not from specific fields or knowledge. Therefore, it is relevant to inquire about the TP, from the teacher himself, as an active subject and not as an object of knowledge; therefore, it is preponderant to recognize the knowledge of the teacher, allowing joint spaces for reflection with other teachers about their work such as a Community of Professional Development of Teachers (CODEP-DO), where they reflect on the nature of learning in the class of sciences Here, the results of the analysis work around the nature of the learning of a CODEP-DO composed of 18 preschool, primary and secondary teachers, who voluntarily participated in a workshop-, when observing the actions carried out by an elementary teacher, presented in the video recording of her class, while working on the topic of classification of living beings and analyzing them from categories such as: student's role, object of learning, achievements and evaluation of learning. Finding that while CODEP-DO identifies with a constructivist vision of science learning, since it recognizes the importance of community work and student interaction, concepts such as 'classification criteria' remain the center of the teaching work.Tanto en el ámbito nacional como en el internacional se encuentra un número importante de investigaciones que abordan el fenómeno de la Práctica Docente y la formación continua de maestros. Sin embargo, la mayoría de éstas abordan la reflexión, análisis y discusión sobre la Práctica Docente (PD) desde perspectivas generalistas, es decir; desde la pedagogía en general y no desde los campos o saberes específicos. Por ello, resulta relevante indagar sobre la PD, desde el docente mismo, como un sujeto activo y no como un objeto de conocimiento; por ende, es preponderante reconocer el saber del profesor, posibilitándole espacios conjuntos de reflexión con otros docentes sobre su quehacer tal como una Comunidad de Desarrollo Profesional Docente (CODEP-DO), donde se reflexione en torno a la naturaleza del aprendizaje en la clase de ciencias. Aquí, se reportan los resultados del trabajo de análisis realizado por 18 docentes de educación básica -preescolar, primaria y secundaria- que conformaron una CODEP-DO de manera voluntaria, al ser convocados a participar en un curso-taller. Ellos observaron una videograbación de las acciones realizadas por una docente de primaria, cuando trabajaba el tema de clasificación de los seres vivos; analizaron las acciones docentes desde categorías tales como: papel del alumno, objeto de aprendizaje, logros y evaluación del aprendizaje. Encontrándose que si bien la CODEP-DO, se identifica con una visión constructivista del aprendizaje de las ciencias, ya que reconoce la importancia del trabajo en comunidad y la interacción entre el alumnado, los conceptos como ‘criterios de clasificación’ siguen siendo el centro del trabajo docente