Screening pulmonary arteriovenous malformations in a large cohort of Spanish patients with hemorrhagic hereditary telangiectasia

39 p.-1 fig.-7 tab.Background and objectives Because of the serious nature of potential complications, screening for pulmonary arteriovenous malformations is required in patients with hereditary hemorrhagic telangiectasia. The aim of this study was to evaluate the utility of contrast echocardiography and compare the performance of two contrast agents: agitated saline and Gelofusine.Material and methods Two hundred and five patients screened for PAVMs using TTCE and computed tomography (CT) performed with an interval of less than 180 days. Contrast echocardiography studies were graded on a 4-point semiquantitative scale based on the amount of microbubbles seen in left heart chambers.Results Positive TTCE findings were seen in 137 (66.8%) patients, whereas CT confirmed PAVMs in 59 (43.1%). Two of 67 grade 1 patients; 18 of 42 grade 2; 17 of 22 grade 3 and all grade 4 had PAVMs on CT. Embolotherapy was feasible in 38.9% patients in grade 2 and 82.3% and 95.2% in grades 3–4. No patients in grade 1 were embolized. The mean cardiac cycle in which bubbles were first seen in the left heart in patients without and with PAVMs on CT was 6.1 and 3.9 (p < 0.0001). Compared to saline, Gelofusine produced an overall increase in grade.Conclusions No grade 1 patients had treatable PAVMs. There is a need for improvement in the selection of patients for CT in grade 2, where less than half have PAVMs on CT. The cardiac cycle may help to differentiate between patients with and without PAVMs. Gelofusine was not better than saline for PAVM screening.This study has been supported by grants from Instituto de Salud Carlos III (ISCIII; PI11/0246 to JAP), FEDER (to JAP), Ministerio de Economía y Competitividad of Spain (SAF2011-23475 to LMB and SAF2013-43421-R to CB), and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER; ISCIIICB06/ 07/0038 to CB).Peer reviewe

Evaluation of endothelial function and subclinical atherosclerosis in patients with HIV infection

The aim of this study was to analyse the association between human immunodefciency virus (HIV) related clinical and analytical parameters and the presence of subclinical atherosclerosis as well as endothelial dysfunction. This was a prospective cohort study of HIV-positive patients who underwent intima media thickness (IMT) determination and coronary artery calcium scoring to determine subclinical atherosclerosis. To detect endothelial dysfunction, the breath holding index, fow-mediated dilation and the concentration of endothelial progenitor cells (EPCs) were measured. Patients with an IMT? 0.9 mm had an average of 559.3 ± 283.34 CD4/?l, and those with an IMT< 0.9 mm had an average of 715.4 ± 389.92 CD4/?l (p= 0.04). Patients with a low calcium score had a signifcantly higher average CD4 cell value and lower zenith viral load (VL) than those with a higher score (707.7 ± 377.5 CD4/?l vs 477.23 ± 235.7 CD4/?l (p= 0.01) and 7 ×?¬104 ± 5 ×?¬104 copies/ml vs 23.4 × 104 ± 19 × 104 copies/ml (p= 0.02)). The number of early EPCs in patients with a CD4 nadir< 350/ µl was lower than that in those with a CD4 nadir? 350 (p= 0.03). In HIV-positive patients, low CD4 cell levels and high VL were associated with risk of developing subclinical atherosclerosis. HIV patients with CD4 cell nadir < 350/µl may have fewer early EPCs

Clinical Factors Associated with Reinfection versus Relapse in Infective Endocarditis: Prospective Cohort Study

We aimed to identify clinical factors associated with recurrent infective endocarditis (IE) episodes. The clinical characteristics of 2816 consecutive patients with definite IE (January 2008?2018) were compared according to the development of a second episode of IE. A total of 2152 out of 2282 (94.3%) patients, who were discharged alive and followed-up for at least the first year, presented a single episode of IE, whereas 130 patients (5.7%) presented a recurrence; 70 cases (53.8%) were due to other microorganisms (reinfection), and 60 cases (46.2%) were due to the same microorganism causing the first episode. Thirty-eight patients (29.2%), whose recurrence was due to the same microorganism, were diagnosed during the first 6 months of follow-up and were considered relapses. Relapses were associated with nosocomial endocarditis (OR: 2.67 (95% CI: 1.37?5.29)), enterococci (OR: 3.01 (95% CI: 1.51?6.01)), persistent bacteremia (OR: 2.37 (95% CI: 1.05?5.36)), and surgical treatment (OR: 0.23 (0.1?0.53)). On the other hand, episodes of reinfection were more common in patients with chronic liver disease (OR: 3.1 (95% CI: 1.65?5.83)) and prosthetic endocarditis (OR: 1.71 (95% CI: 1.04?2.82)). The clinical factors associated with reinfection and relapse in patients with IE appear to be different. A better understanding of these factors would allow the development of more effective therapeutic strategies

doi.org/10.1371/journal. pone.0250796

The aim was to analyze the characteristics and predictors of unfavorable outcomes in solid organ transplant recipients (SOTRs) with COVID-19. We conducted a prospective observational cohort study of 210 consecutive SOTRs hospitalized with COVID-19 in 12 Spanish centers from 21 February to 6 May 2020. Data pertaining to demographics, chronic underlying diseases, transplantation features, clinical, therapeutics, and complications were collected. The primary endpoint was a composite of intensive care unit (ICU) admission and/or death. Logistic regression analyses were performed to identify the factors associated with these unfavorable outcomes. Males accounted for 148 (70.5%) patients, the median age was 63 years, and 189 (90.0%) patients had pneumonia. Common symptoms were fever, cough, gastrointestinal disturbances, and dyspnea. The most used antiviral or host-targeted therapies included hydroxychloroquine 193/200 (96.5%), lopinavir/ritonavir 91/200 (45.5%), and tocilizumab 49/200 (24.5%). Thirty-seven (17.6%) patients required ICU admission, 12 (5.7%) suffered graft dysfunction, and 45 (21.4%) died. A shorter interval between transplantation and COVID-19 diagnosis had a negative impact on clinical prognosis. Four baseline features were identified as independent predictors of intensive care need or death: advanced age, high respiratory rate, lymphopenia, and elevated level of lactate dehydrogenase. In summary, this study presents comprehensive information on characteristics and complications of COVID-19 in hospitalized SOTRs and provides indicators available upon hospital admission for the identification of SOTRs at risk of critical disease or death, underlining the need for stringent preventative measures in the early post-transplant periodThis study was supported by Plan Nacional de I+D+i 2013-2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016); co-financed by European Development Regional Fund “A way to achieve Europe”, Operative Program Intelligence Growth 2014-2020. EC and JSC received grants from the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, Proyectos de Investigación sobre el SARSCoV-2 y la enfermedad COVID-19 (COV20/ 00370; COV20/00580). JSC is a researcher belonging to the program “Nicola´s Monardes”(C0059–2018), Servicio Andaluz de Salud, Junta de Andalucía, Spain. SS-A is supported by a grant from the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, Proyectos de Investigación sobre el SARS-Co

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES)

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES) doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidencebased guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.Funding: J.M. Miró was a recipient of a personal 80:20 research grant from IDIBAPS during the period 2017–2021

Effect of the type of surgical indication on mortality in patients with infective endocarditis who are rejected for surgical intervention

AIM: To evaluate the effect of the type of surgical indication on mortality in infective endocarditis (IE) patients who are rejected for surgery. METHODS AND RESULTS: From January 2008 to December 2016, 2714 patients with definite left-sided IE were attended in the participating hospitals. One thousand six hundred and fifty-three patients (60.9%) presented surgical indications. Five hundred and thirty-eight patients (32.5%) presented surgical indications but received medical treatment alone. The indications for surgery in these patients were uncontrolled infection (366 patients, 68%), heart failure (168 patients, 31.3%) and prevention of embolism (148 patients, 27.6%). One hundred and thirty patients (24.2%) presented more than one indication. The mortality during hospital admission was 60% (323 patients). The in-hospital mortality of patients whose indication for surgery was heart failure, uncontrolled infection or risk of embolism was 75.6%, 61.4% and 54.7%, respectively (p?<?0.001). Surgical indications due to heart failure (OR: 3.24; CI 95%: 1.99-5.9) or uncontrolled infection (OR: 1.83; CI 95%: 1.04-3.18) were independently associated with a fatal outcome during hospital admission. Mortality during the first year was 75.4%. The mortality during the first year in patients whose indication for surgery was heart failure, uncontrolled infection or risk of embolism was 85.9%, 76.7% and 72.7%, respectively (p?=?0.016). Surgical indication due to heart failure (OR: 3.03; CI 95%: 1.53-5.98) were independently associated with fatal outcome during the first year. CONCLUSIONS: The type of surgical indication is associated with mortality in IE patients who are rejected for surgical intervention

Risk factors for unfavorable outcome and impact of early post-transplant infection in solid organ recipients with COVID-19: A prospective multicenter cohort study

The aim was to analyze the characteristics and predictors of unfavorable outcomes in solid organ transplant recipients (SOTRs) with COVID-19. We conducted a prospective observational cohort study of 210 consecutive SOTRs hospitalized with COVID-19 in 12 Spanish centers from 21 February to 6 May 2020. Data pertaining to demographics, chronic underlying diseases, transplantation features, clinical, therapeutics, and complications were collected. The primary endpoint was a composite of intensive care unit (ICU) admission and/or death. Logistic regression analyses were performed to identify the factors associated with these unfavorable outcomes. Males accounted for 148 (70.5%) patients, the median age was 63 years, and 189 (90.0%) patients had pneumonia. Common symptoms were fever, cough, gastrointestinal disturbances, and dyspnea. The most used antiviral or host-targeted therapies included hydroxychloroquine 193/200 (96.5%), lopinavir/ritonavir 91/200 (45.5%), and tocilizumab 49/200 (24.5%). Thirty-seven (17.6%) patients required ICU admission, 12 (5.7%) suffered graft dysfunction, and 45 (21.4%) died. A shorter interval between transplantation and COVID-19 diagnosis had a negative impact on clinical prognosis. Four baseline features were identified as independent predictors of intensive care need or death: advanced age, high respiratory rate, lymphopenia, and elevated level of lactate dehydrogenase. In summary, this study presents comprehensive information on characteristics and complications of COVID-19 in hospitalized SOTRs and provides indicators available upon hospital admission for the identification of SOTRs at risk of critical disease or death, underlining the need for stringent preventative measures in the early post-transplant period

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

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

Particularidades técnicas del tratamiento endovascular en población adulta y pediátrica con ictus isquémico agudo

El tractament endovascular de l'ictus isquèmic agut ha suposat un impacte inigualable en els resultats funcionals d'aquests pacients. Els avenços en les tècniques, materials i dispositius han anat a l'una amb els coneixements que s'han anat adquirint pel personal sanitari en els últims anys. Malgrat aquests avenços hi ha diversos problemes, dificultats o contrarietats en el tractament endovascular d'aquesta patologia. Per ajudar a resoldre alguns d'aquests dilemes vam realitzar un estudi de cohorts prospectiu en el qual ens plantegem analitzar els resultats clínics i radiològics dels pacients amb complicacions arterials intraprocedimiento (CAI), l'efecte de l'alteplasa sistèmica combinada amb la trombectomía mecànica (TM) i l'efectivitat dels diferents dispositius de recanalització endovascular de tercera generació. Així mateix, vam analitzar el perfil d'eficàcia i seguretat de la TM en pacients menors de 18 anys amb ictus isquèmic agut. Les CAI, que afortunadament tenen lloc en una petita proporció dels pacients tractats amb TM, s'associen amb pitjors resultats clínics i radiològics tant a curt com a llarg termini. Sembla que la infusió prèvia de alteplasa de forma sistèmica ajuda a el tractament endovascular reduint la durada de l'procediment, augmentant la taxa de recanalització completa i d'independència funcional. No sembla que hi hagi diferències entre els diferents models de stentrievers existents al mercat. Sembla que la TM és una tècnica segura i eficaç en pacients menors de 18 anys amb ictus isquèmic agut i discordança clínic-radiològica. Especialment en pacients adolescents que compleixen criteris clínics i radiològics similars als dictats en les guies internacionals estandarditzades de tractament per a adults.El tratamiento endovascular del ictus isquémico agudo ha supuesto un impacto inigualable en los resultados funcionales de estos pacientes. Los avances en las técnicas, materiales y dispositivos han ido a la par con los conocimientos que se han ido adquiriendo por el personal sanitario en los últimos años. A pesar de estos avances existen diversos problemas, dificultades o contrariedades en el tratamiento endovascular de esta patología. Para ayudar a resolver algunos de estos dilemas realizamos un estudio de cohortes prospectivo en el que nos planteamos analizar los resultados clínicos y radiológicos de los pacientes con complicaciones arteriales intraprocedimiento (CAI), el efecto de la alteplasa sistémica combinada con la trombectomía mecánica (TM) y la efectividad de los distintos dispositivos de recanalización endovascular de tercera generación. Así mismo, analizamos el perfil de eficacia y seguridad de la TM en pacientes menores de 18 años con ictus isquémico agudo. Las CAI, que afortunadamente ocurren en una pequeña proporción de los pacientes tratados con TM, se asocian con peores resultados clínicos y radiológicos tanto a corto como a largo plazo. Parece que la infusión previa de alteplasa de forma sistémica ayuda al tratamiento endovascular reduciendo la duración del procedimiento, aumentando la tasa de recanalización completa y de independencia funcional. No parece que haya diferencias entre los diferentes modelos de stentrievers existentes en el mercado. Parece que la TM es una técnica segura y eficaz en pacientes menores de 18 años con ictus isquémico agudo y discordancia clínico-radiológica. Especialmente en pacientes adolescentes que cumplen criterios clínicos y radiológicos similares a los dictados en las guías internacionales estandarizadas de tratamiento para adultos.Endovascular treatment of acute ischemic stroke has had a unique impact on the functional outcomes of large vessel occlusion patients. Advances in techniques, materials and devices have gone hand in hand with the knowledge that has been acquired by healthcare personnel in recent years. Despite these advances, there are various problems, difficulties or setbacks in the endovascular treatment of this pathology. To help resolve some of these dilemmas, we conducted a prospective cohort study in which we planned to analyze the clinical and radiological results of patients with intraprocedural complications, the effect of alteplase combined with mechanical thrombectomy, and the effectiveness of the various third-generation endovascular recanalization devices. Likewise, we analyzed the safety profile of TM in patients under 18 years of age with acute ischemic stroke. Intraprocedural complications, which fortunately occur in a small proportion of patients treated with mechanical thrombectomy are associated with poorer clinical and radiological outcomes both in the short and long term. It seems that the previous infusion of alteplase systemically helps endovascular treatment by reducing the duration of the procedure, increasing the rate of complete recanalization and functional independence. There does not seem to be any difference between the different models of stentrievers on the market. It seems that mechanical thrombectomy is a safe and effective technique in patients under 18 years of age with acute ischemic stroke and clinical-radiological discordance. Especially in teenagers who meet clinical and radiological criteria, similar to those dictated in standardized international treatment guidelines for adults.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin