Writing a Case Report: A Work of Art

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Saturación Renal de Oxígeno como nuevo marcador para la Insuficiencia Renal Aguda asociada a la Cirugía Cardiaca en el Adulto

Introducción La insuficiencia renal aguda es una complicación grave y el factor de riesgo más fuerte de muerte en pacientes sometidos a cirugía cardíaca. La relación entre la saturación cerebral y renal de oxígeno en el postoperatorio y la insuficiencia renal aguda en adultos sometidos a cirugía cardíaca no ha sido determinada. Diseñamos un estudio prospectivo de un solo centro para determinar si la monitorización continua de la saturación cerebral y renal de oxígeno intraoperatoria y postoperatoria podría predecir la insuficiencia renal aguda asociado a la cirugía cardiaca. Métodos Estudio prospectivo de una cohorte de 121 pacientes intervenidos entre enero y septiembre de 2017. El resultado primario fue el desarrollo de insuficiencia renal aguda postoperatoria utilizando los criterios para mejorar los resultados global de la enfermedad renal (KDIGO Kidney Disease Improving Global Outcome, por sus siglas en inglés). La saturación cerebral y renal de oxígeno se registraron durante las primeras 48 h después de la cirugía cardíaca. El análisis de la curva ROC se utilizó para evaluar el poder predictivo de la saturación renal de oxígeno para la insuficiencia renal aguda. Resultados Un total de treinta y cinco (28.9%) pacientes desarrollaron insuficiencia renal aguda. Aunque la saturación cerebral no mostró diferencias estadísticas significativas en ambos grupos, la saturación renal se relacionó con la insuficiencia renal aguda (p = 0,001). El análisis de la curva ROC mostró que la saturación renal de oxígeno podría predecir el riesgo de insuficiencia renal aguda. La saturación renal de oxígeno < 65% (Área bajo curva-ROC: 0,679 ± 0,054, IC del 95%: 0,573-0,785, p <0,002) y un 20% de desaturación desde la línea de base (Área bajo curva-ROC: 0,639 ± 0,059, 95% CI 0.523-0.755, p <0.019) mostraron el mejor rendimiento, respectivamente. Conclusiones Nuestro estudio demostró que la saturación renal de oxígeno en el postoperatorio está relacionada con el desarrollo de insuficiencia renal aguda asociada a la cirugía cardíaca. Sugerimos que la monitorización continua de la saturación renal de oxígeno podría ser una herramienta prometedora no invasiva para predecir la insuficiencia renal aguda durante el período postoperatorio de la cirugía cardíaca en adultos.Departamento de Cirugía, Oftalmología, Otorrinolaringología y FisioterapiaDoctorado en Investigación en Ciencias de la Salu

Predictors of postoperative acute kidney injury after coronary artery bypass graft surgery

Producción CientíficaObjective: The aims of this study were to identify the risk factors associated with acute kidney injury (AKI) after isolated surgical revascularization with cardiopulmonary bypass and to develop a model to predict the appearance of postoperative AKI. Methods: A total of 435 adult patients who underwent primary isolated coronary artery bypass graft (CABG) surgery, from 2012 to 2016, in the Clinic University Hospital of Valladolid (Spain) were enrolled. AKI was defined according to the risk, injury, failure, loss, and end-stage (RIFLE) criteria. Data were collected from hospital electronic medical records. Multiple logistic regression analysis was used to identify risk factors. Results: The prevalence of AKI was 12.4%. Multivariate analysis identified age (odds ratio [OR], 1.056; 95% confidence interval [CI], 1.016-1.098; P=0.005), hypertension (OR, 3.078; 95% CI, 1.151-8.230; P=0.018), low ejection fraction (EF) (OR, 6.785; 95% CI, 2.080-22.135; P=0.001), estimated glomerular filtration rate (eGFR) (OR, 1.017; 95% CI, 1.005-1.028; P=0.014), EuroSCORE II (OR, 1.049; 95% CI, 1.004-1.096; P=0.033), and no intake of calcium-channel blockers (CCB) (OR, 4.892; 95% CI, 1.496-16.025; P=0.022) as risk factors for AKI. These risk factors were included in a model to predict postoperative AKI with an area under a receiver operating characteristic curve of 0.783±0.036 (95% CI, 0.713-0.854; P<0.0001). Conclusion: Age, hypertension, low EF, eGFR, EuroSCORE II, and no intake of CCB were independent risk factors for postoperative AKI. These factors provide an easy and accurate model to predict postoperative AKI in patients undergoing cardiac surgery

Desarrollo de liderazgo docente mediante programación neurolingüística

Objetivos Generales: • Diagnosticar si los estudiantes de la carrera de Docencia Media Diversificada poseen competencias para desarrollar liderazgo en su labor docente. • Proponer alternativas de mejoramiento en estudiantes de la carrera de Docencia Media Diversificada. Objetivos Específicos: • Definir las variables de investigación. • Aplicar los instrumentos de recolección de información. • Tabular y analizar los resultados obtenidos en el estudio. • Evaluar la pertinencia de utilizar los resultados obtenidos en futuras investigaciones sobre el tema del liderazgo docente. • Generar proyectos en función de los resultados obtenidos

Extracorporeal Circulation in Cardiac Surgery Inflammatory response, controversies and Future Directions

One of the milestones in the history of the cardiac surgery is the development of extracorporeal circulation, which allowed hundreds of thousands of patients under successful open cardiac surgery. It´s objective is to maintain the vital organ´s perfusion, provide a bloodless field for surgery, and at the same time, give protection to the heart and lungs. Its principle is to bring most or all of the patient’s systemic blood, which normally returns to the right atrium, into an oxygenator in which oxygen is supplied to the blood and carbon dioxide is removed. The arterialized blood is filtered, heated and, pumped into the aorta and the systemic arterial system. But this continuous blood recirculation through nonendothelial surfaces of the perfusion system produces an inflammatory response. Despite all the advantages and strategies developed to try to make the most physiological condition during the extracorporeal circulation, there are still persistent controversies, which we are going to review, as well as the inflammatory response produced by the perfusion system, and it´s future directions

Near-infrared spectroscopy monitoring in cardiac and noncardiac surgery: Pairwise and network meta-analyses

Producción CientíficaGoal-directed therapy based on brain-oxygen saturation (bSo2) is controversial and hotly debated. While meta-analyses of aggregated data have shown no clinical benefit for brain near-infrared spectroscopy (NIRS)-based interventions after cardiac surgery, no network meta-analyses involving both major cardiac and noncardiac procedures have yet been undertaken. Randomized controlled trials involving NIRS monitoring in both major cardiac and noncardiac surgery were included. Aggregate-level data summary estimates of critical outcomes (postoperative cognitive decline (POCD)/postoperative delirium (POD), acute kidney injury, cardiovascular events, bleeding/need for transfusion, and postoperative mortality) were obtained. NIRS was only associated with protection against POCD/POD in cardiac surgery patients (pooled odds ratio (OR)/95% confidence interval (CI)/I2/number of studies (n): 0.34/0.14–0.85/75%/7), although a favorable effect was observed in the analysis, including both cardiac and noncardiac procedures. However, the benefit of the use of NIRS monitoring was undetectable in Bayesian network meta-analysis, although maintaining bSo2 > 80% of the baseline appeared to have the most pronounced impact. Evidence was imprecise regarding acute kidney injury, cardiovascular events, bleeding/need for transfusion, and postoperative mortality. There is evidence that brain NIRS-based algorithms are effective in preventing POCD/POD in cardiac surgery, but not in major noncardiac surgery. However, the specific target bSo2 threshold has yet to be determined.Junta de Castilla y León (project VA161G18

Nosocomial Vs. Community-Acquired Infective Endocarditis in Spain: Location, Trends, Clinical Presentation, Etiology, and Survival in the 21st Century

Major changes have occurred in the epidemiology and etiology of infective endocarditis (IE). Nevertheless, the differences between nosocomial infective endocarditis (NIE) and community-acquired infective endocarditis (CIE) have not been addressed in a population-based study. We conducted a retrospective, nationwide, temporal trend study from 1997 to 2014 analyzing the epidemiology, clinical, geographical, meteorological characteristics of patients diagnosed with IE in Spain, to distinguish NIE from CIE. Among 25,952 patients with IE (62.2 ± 18·6 years; 65.9% men), 45.9% had NIE. The incidence of IE increased from 2.83 to 3.73 due to the NIE incidence increment with a decline in CIE. Patients with NIE were older (63.8 years vs. 60.8 years, p < 0·001), presented a higher Charlson index (1.22 vs. 1.03, p < 0.001), a greater history of implanted cardiac devices (8.7% vs. 4.6%, p < 0.001), and higher mortality (31.5% vs. 21.7%, p < 0.001). The most frequent microorganism for both NIE and CIE was Staphylococcus (p < 0.001), and the North reported a higher incidence (p < 0.001). Risk factors of mortality for NIE were age, Charlson index, hemodialysis, shock, heart failure, and stroke. Risk factors for CIE included female sex, renal disease, and cardiac-device carriers. The etiology of IE shifted from community origins to mostly nosocomial-associated infections. Higher morbidity, mortality, and poorer outcomes are associated with NIE.This research received no external funding. The authors thank Consejería de Educación, Junta de Castilla y León, Spain (reference: VA161G18), for covering the publication charges of this article.S

The overlooked immune state in candidemia: A risk factor for mortality

Producción CientíficaLymphopenia has been related to increased mortality in septic patients. Nonetheless, the impact of lymphocyte count on candidemia mortality and prognosis has not been addressed. We conducted a retrospective study, including all admitted patients with candidemia from 2007 to 2016. We examined lymphocyte counts during the first 5 days following the diagnosis of candidemia. Multivariable logistic regression analysis was performed to determine the relationship between lymphocyte count and mortality. Classification and Regression Tree analysis was used to identify the best cut-off of lymphocyte count for mortality associated with candidemia. From 296 cases of candidemia, 115 died, (39.8% 30-day mortality). Low lymphocyte count was related to mortality and poor outcome (p < 0.001). Lymphocyte counts <0.703 × 109 cells/L at diagnosis (area under the curve (AUC)-ROC, 0.783 ± 0.042; 95% confidence interval (CI), 0.700–0.867, p < 0.001), and lymphocyte count <1.272 × 109 cells/L five days later (AUC-ROC, 0.791 ± 0.038; 95%CI, 0.716–0.866, p < 0.001) increased the odds of mortality five-fold (odds ratio (OR), 5.01; 95%CI, 2.39–10.93) at time of diagnosis, and three-fold (OR, 3.27; 95%CI, 1.24–8.62) by day 5, respectively. Low lymphocyte count is an independent predictor of mortality in patients with candidemia and might serve as a biomarker for predicting candidemia-associated mortality and poor outcome.Junta de Castilla y León (grant VA161G18

Gene Expression Patterns Distinguish Mortality Risk in Patients with Postsurgical Shock

Producción CientíficaNowadays, mortality rates in intensive care units are the highest of all hospital units. However, there is not a reliable prognostic system to predict the likelihood of death in patients with postsurgical shock. Thus, the aim of the present work is to obtain a gene expression signature to distinguish the low and high risk of death in postsurgical shock patients. In this sense, mRNA levels were evaluated by microarray on a discovery cohort to select the most differentially expressed genes between surviving and non-surviving groups 30 days after the operation. Selected genes were evaluated by quantitative real-time polymerase chain reaction (qPCR) in a validation cohort to validate the reliability of data. A receiver-operating characteristic analysis with the area under the curve was performed to quantify the sensitivity and specificity for gene expression levels, which were compared with predictions by established risk scales, such as acute physiology and chronic health evaluation (APACHE) and sequential organ failure assessment (SOFA). IL1R2, CD177, RETN, and OLFM4 genes were upregulated in the non-surviving group of the discovery cohort, and their predictive power was confirmed in the validation cohort. This work offers new biomarkers based on transcriptional patterns to classify the postsurgical shock patients according to low and high risk of death. The results present more accuracy than other mortality risk scores.Instituto de Salud Carlos III (grant PI15/01451)Junta de Castilla y León (grant 1255/A/16)Universidad de Valladolid - Fondo Europeo de Desarrollo Regional (grant VA321P18

Predictive modeling of poor outcome in severe COVID-19: A single-center observational study based on clinical, cytokine and laboratory profiles

Producción CientíficaPneumonia is the main cause of hospital admission in COVID-19 patients. We aimed to perform an extensive characterization of clinical, laboratory, and cytokine profiles in order to identify poor outcomes in COVID-19 patients. Methods: A prospective and consecutive study involving 108 COVID-19 patients was conducted between March and April 2020 at Hospital Clínico Universitario de Valladolid (Spain). Plasma samples from each patient were collected after emergency room admission. Forty-five serum cytokines were measured in duplicate, and clinical data were analyzed using SPPS version 25.0. Results: A multivariate predictive model showed high hepatocyte growth factor (HGF) plasma levels as the only cytokine related to intubation or death risk at hospital admission (OR = 7.38, 95%CI—(1.28–42.4), p = 0.025). There were no comorbidities included in the model except for the ABO blood group, in which the O blood group was associated with a 14-fold lower risk of a poor outcome. Other clinical variables were also included in the predictive model. The predictive model was internally validated by the receiver operating characteristic (ROC) curve with an area under the curve (AUC) of 0.94, a sensitivity of 91.7% and a specificity of 95%. The use of a bootstrapping method confirmed these results. Conclusions: A simple, robust, and quick predictive model, based on the ABO blood group, four common laboratory values, and one specific cytokine (HGF), could be used in order to predict poor outcomes in COVID-19 patients.Instituto de Salud Carlos III - ( Proyecto COV20/00491)Consejeria de Educación de Castilla y León - (Proyecto VA256P20)Junta de Castilla y León y Fondo Europeo de Desarrollo Regional (FEDER) - (Proyecto EDU/1100/2017