Real-World Multicenter Experience of Immunosuppression Minimization Among 661 Liver Transplant Recipients.

BACKGROUND Long-term morbidity and mortality in liver transplant recipients is frequently secondary to immunosuppression toxicity. However, data are scarce regarding immunosuppression minimization in clinical practice. MATERIAL AND METHODS In this cross-sectional, multicenter study, we reviewed the indications of immunosuppression minimization (defined as tacrolimus levels below 5 ng/mL or cyclosporine levels below 50 ng/mL) among 661 liver transplant recipients, as well as associated factors and the effect on renal function. RESULTS Fifty-three percent of the patients received minimized immunosuppression. The median time from transplantation to minimization was 32 months. The most frequent indications were renal insufficiency (49%), cardiovascular risk (19%), de novo malignancy (8%), and cardiovascular disease (7%). The factors associated with minimization were older age at transplantation, longer post-transplant follow-up, pre-transplant diabetes mellitus and renal dysfunction, and the hospital where the patients were being followed. The patients who were minimized because of renal insufficiency had a significant improvement in renal function (decrease of the median serum creatinine level, from 1.50 to 1.34 mg/dL; P=0.004). Renal function significantly improved in patients minimized for other indications, too. In the long term, glomerular filtration rate significantly decreased in non-minimized patients and remained stable in minimized patients. CONCLUSIONS Immunosuppression minimization is frequently undertaken in long-term liver transplant recipients, mainly for renal insufficiency. Substantial variability exists regarding the use of IS minimization among centers

Descriptive analysis of the use of atypical antipsychotics under compassionate-use in a health area in Ferrol (La Coruña, Spain)

Background and objective: Although atypical antipsychotics (AA) provoke fewer extrapyramidal symptoms (ES) than classic antipsychotics, their use in patients greater than or equal to 75 years old with dementia must be under compassionate-use. This is an important limitation. We performed a descriptive analysis of the use of atypical antipsychotics under compassionate-use (AACU) in the Ferrol health area. Patients and methods: We retrospectively assessed all the patients who were receiving an AACU from March, 2004 (that is the date when prescription under compassionate-use of AA came into force in Spain) to 30 November, 2008. Results: One hundred and thirty-three of 164 patients (63.6% women; median ages, 81.9±4.95 years) were included. Diagnostic aetiologies were: 42.9% Alzheimer disease, 30.8% Parkinson-dementia/Lewy body disease, and 15.8% vascular/mixed dementia. A total of 68.4% of patients had received other anti-psychotic drugs previously and 32.3% had ES due to antipsychotics. The AACU received were: quetiapine (76.7%), ziprasidone (18.8%), and olanzapine (4.5%). Median follow-uptime was 20.25±20.38 months. Side effects were observed in 19.7% of patients. Improvement of NPI (Neuropsychiatric Inventory) was 33.3±24.75 points. Agitation/aggressiveness (5.6±4.55), delirious ideas (4.94±5.07), irritability (4.38±4.94), and anxiety (4.32±4.83) were the symptoms that most improved. Although there were no differences between AACU, quetiapine was associated with significant maintenance in monotherapy (94.1% vs 72% for ziprasidone and 83.3% for olanzapine; p < 0.0001). Conclusions: AACU are effective and well tolerated drugs. Quetiapine was the most frequently used AACU. An excessive percentage of patients previously received other antipsychotics and present with ES. Resumen: Objetivos: Aunque quetiapina y ziprasidona producen menos síntomas extrapiramidales (SEP) que otros antipsicóticos, su uso en pacientes mayores de 75 años con demencia se ve condicionado por la obligatoriedad de prescribirlos “por uso compasivo”. Realizamos un análisis descriptivo del uso de antipsicóticos atípicos de uso compasivo (AAUC) en el área sanitaria de Ferrol. Pacientes y métodos: Incluimos a todos los pacientes que recibieran un AAUC desde marzo de 2004 (fecha en que entró en vigor la dispensación de AAUC) hasta el 30-11-2008. Resultados: Se incluyó a 133 de un total de 164 pacientes (el 63,6%, mujeres; media±desviación estándar de edad, 81,9 ± 4,95 años). El 94,1% presentaba demencia (el 42,9%, enfermedad de Alzheimer; el 30,8%, demencia-enfermedad de Parkinson, y el 15,8%, demencia vascular/mixta). El 68,4% había recibido algún otro antipsicótico previo y el 32,3% presentaba SEP secundarios. Los AAUC prescritos fueron: quetiapina (76,7%), ziprasidona (18,8%) y olanzapina (4,5%). La media de tiempo de seguimiento fue 20,25 ± 20,38 meses. El cumplimiento terapéutico fue del 95,5%. El 19,7% presentó efectos secundarios. La media de mejora en la escala NPI (Neuropsychiatric Inventory) fue 33,3 ± 24,75 puntos. La agitación/agresividad (5,6 ± 4,55), las ideas delirantes (4,94 ± 5,07), la irritabilidad (4,38 ± 4,94) y la ansiedad (4,32 ± 4,83) fueron los síntomas que más mejoraron. Aunque no hubo diferencias entre los 3 AAUC, quetiapina conllevó un mayor mantenimiento en monoterapia (el 94,1 frente al 72% de ziprasidona y el 83,3% de olanzapina; p < 0,0001). Conclusiones: Los AAUC son fármacos efectivos y bien tolerados. Quetiapina es el AAUC más utilizado. Un porcentaje excesivo de pacientes reciben antes otros antipsicóticos y presentan SEP. Keywords: Agitation, Anti-psychotic, Behaviour, Dementia, Neuroleptic drugs, Quetiapine, Palabras clave: Agitación, Antipsicótico, Demencia, Neuroléptico, Quetiapina, Trastorno conductua

Design and Performance of a New Severity Score for Intermediate Care

Application of illness-severity scores in Intermediate Care Units (ImCU) shows conflicting results. The aim of the study is to design a severity-of-illness score for patients admitted to an ImCU.We performed a retrospective observational study in a single academic medical centre in Pamplona, Spain. Demographics, past medical history, reasons for admission, physiological parameters at admission and during the first 24 hours of ImCU stay, laboratory variables and survival to hospital discharge were recorded. Logistic regression analysis was performed to identify variables for mortality prediction.A total of 743 patients were included. The final multivariable model (derivation cohort = 554 patients) contained only 9 variables obtained at admission to the ImCU: previous length of stay 7 days (6 points), health-care related infection (11), metastatic cancer (9), immunosuppressive therapy (6), Glasgow comma scale 12 (10), need of non-invasive ventilation (14), platelets 50000/mcL (9), urea 0.6 g/L (10) and bilirubin 4 mg/dL (9). The ImCU severity score (ImCUSS) is generated by summing the individual point values, and the formula for determining the expected in-hospital mortality risk is: e(ImCUSS points*0.099 - 4,111)/(1 + e(ImCUSS points*0.099 - 4,11)1). The model showed adequate calibration and discrimination. Performance of ImCUSS (validation cohort = 189 patients) was comparable to that of SAPS II and 3. Hosmer-Lemeshow goodness-of-fit C test was χ2 8.078 (p=0.326) and the area under receiver operating curve 0.802.ImCUSS, specially designed for intermediate care, is based on easy to obtain variables at admission to ImCU. Additionally, it shows a notable performance in terms of calibration and mortality discrimination

Heart Rate and Mortality in Patients With Acute Symptomatic Pulmonary Embolism

International audienc

Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2