Relación entre escalas de predicción de riesgo quirúrgico y escalas de fragilidad con resultados negativos geriátricos en pacientes ancianos sometidos a cirugía cardíaca

La fragilidad puede ser útil para la estimación del riesgo quirúrgico en pacientes de edad avanzada candidatos a cirugía cardíaca, aunque se desconoce la mejor manera de estimar dicha relación en la clínica. Nuestros objetivos son estudiar la relación de diferentes escalas de riesgo y fragilidad con la aparición de eventos adversos geriátricos, evaluar su aplicabilidad, valorar qué escala de fragilidad predice mejor el desarrollo de resultados negativos y evaluar la evolución de la calidad de vida y del estado funcional de los pacientes ancianos intervenidos de cirugía cardíaca. MATERIAL Y MÉTODOS Se realizó un estudio observacional prospectivo multicéntrico para pacientes de 70 años o más sometidos a cirugía cardíaca con circulación extracorporea. La fragilidad fue evaluada por medio de los criterios fenotípicos de Fried, la escala FRAIL y la Clinical Frailty Scale (CFS). El riesgo quirúrgico se midió con EuroSCORE original, EuroSCORE II y STS Score. Los pacientes fueron evaluados previamente a la cirugía, al alta y después de los 6 meses, estimándose la capacidad funcional, la calidad de vida, la mortalidad, el delirio, el uso de los recursos sanitarios y sociales y la satisfacción con los resultados de la intervención. RESULTADOS Se incluyeron 137 pacientes. Una mayor fragilidad cuantificada con la CFS se relacionó con más visitas a urgencias, más mortalidad, mayor pérdida funcional y mayor prevalencia de delirio, así como menor satisfacción con los resultados. XIV Un mayor riesgo quirúrgico con EuroSCORE II se relacionó con una mayor mortalidad, más reingresos hospitalarios, institucionalización y necesidad de implementación de ayuda domiciliaria. A pesar de que, en general, los pacientes no mejoraron su capacidad funcional, apenas el 11% expresaron deterioro en la calidad de vida y el 83,5% expresaron satisfacción con los resultados de la cirugía. CONCLUSIONES Las escalas de fragilidad son aplicables en la práctica cardioquirúrgica habitual. La CFS puede ser una buena herramienta para predecir los resultados negativos para la salud en ancianos candidatos a cirugía cardíaca. La percepción de la calidad de vida postoperatoria no se relaciona con el estado funcional evolutivo. La calidad de vida tiende a mejorar en los pacientes ancianos intervenidos.Frailty may be useful for estimating surgical risk in elderly patients who are candidates for cardiac surgery, although the best way to quantify it in the clinic is unknown. Our objectives are to study the relationship of different scales of risk and frailty with the occurrence of geriatric adverse events, evaluate their applicability, assess which scale of frailty best predicts the development of negative results and evaluate the evolution of the quality of life and functional status of elderly patients undergoing cardiac surgery. MATERIAL AND METHODS A prospective multicenter observational study was conducted for patients aged 70 years or older undergoing cardiac surgery with extracorporeal circulation. Frailty was assessed using Fried's phenotypic criteria, the FRAIL scale and the Clinical Frailty Scale (CFS). Surgical risk was measured with original EuroSCORE, EuroSCORE II and STS Score. Patients were evaluated before surgery, at the moment of discharge and after 6 months, measuring functional capacity, quality of life, mortality, delirium, use of health and social resources, and satisfaction with the results of the intervention. RESULTS We included 137 patients. A higher frailty quantified with CFS was associated with more emergency room visits, more mortality, greater functional loss, and higher prevalence of delirium, as well as lower satisfaction with the results. A higher surgical risk with EuroSCORE II was related to higher mortality, more hospital readmissions, institutionalization, and the need for in-home help implementation. Although, in general, patients did not improve their functional capacity, only 11% expressed deterioration in quality of life, and 83.5% expressed satisfaction with the results of surgery. CONCLUSIONS Frailty scales are applicable in usual cardiosurgical practice. CFS can be a good tool for assessing negative health outcomes in older candidates for cardiac surgery. The perception of postoperative quality of life is not related to the functional state at follow up. The quality of life tends to improve in the elderly patients who have undergone surgery

Spatiotemporal Characteristics of the Largest HIV-1 CRF02_AG Outbreak in Spain: Evidence for Onward Transmissions

Background and Aim: The circulating recombinant form 02_AG (CRF02_AG) is the predominant clade among the human immunodeficiency virus type-1 (HIV-1) non-Bs with a prevalence of 5.97% (95% Confidence Interval-CI: 5.41–6.57%) across Spain. Our aim was to estimate the levels of regional clustering for CRF02_AG and the spatiotemporal characteristics of the largest CRF02_AG subepidemic in Spain.Methods: We studied 396 CRF02_AG sequences obtained from HIV-1 diagnosed patients during 2000–2014 from 10 autonomous communities of Spain. Phylogenetic analysis was performed on the 391 CRF02_AG sequences along with all globally sampled CRF02_AG sequences (N = 3,302) as references. Phylodynamic and phylogeographic analysis was performed to the largest CRF02_AG monophyletic cluster by a Bayesian method in BEAST v1.8.0 and by reconstructing ancestral states using the criterion of parsimony in Mesquite v3.4, respectively.Results: The HIV-1 CRF02_AG prevalence differed across Spanish autonomous communities we sampled from (p < 0.001). Phylogenetic analysis revealed that 52.7% of the CRF02_AG sequences formed 56 monophyletic clusters, with a range of 2–79 sequences. The CRF02_AG regional dispersal differed across Spain (p = 0.003), as suggested by monophyletic clustering. For the largest monophyletic cluster (subepidemic) (N = 79), 49.4% of the clustered sequences originated from Madrid, while most sequences (51.9%) had been obtained from men having sex with men (MSM). Molecular clock analysis suggested that the origin (tMRCA) of the CRF02_AG subepidemic was in 2002 (median estimate; 95% Highest Posterior Density-HPD interval: 1999–2004). Additionally, we found significant clustering within the CRF02_AG subepidemic according to the ethnic origin.Conclusion: CRF02_AG has been introduced as a result of multiple introductions in Spain, following regional dispersal in several cases. We showed that CRF02_AG transmissions were mostly due to regional dispersal in Spain. The hot-spot for the largest CRF02_AG regional subepidemic in Spain was in Madrid associated with MSM transmission risk group. The existence of subepidemics suggest that several spillovers occurred from Madrid to other areas. CRF02_AG sequences from Hispanics were clustered in a separate subclade suggesting no linkage between the local and Hispanic subepidemics

Memoria para Optar a la Jefatura del Servicio de Cirugía Cardiovascular del Complejo Hospitalario Universitario de Canarias

Propósito del documento El propósito del presente trabajo es presentar una memoria de gestión que me permita optar a la Jefatura del Servicio de Cirugía Cardiovascular del Hospital Universitario de Canarias

Quality of life for elderly patients with acute heart failure: Is it time to talk?

Sin financiación3.350 JCR (2018) Q1, 4/29 Emergency Medicine0.346 SJR (2018) Q2, 38/89 Emergency MedicineNo data IDR 2018UE

Impact of bendopnea on postoperative outcomes in patients with severe aortic stenosis undergoing aortic valve replacement

Bendopnea is a recently described symptom of advanced heart failure. Its prevalence and prognostic utility in other cardiac conditions are unknown. METHODS: We prospectively enrolled 108 consecutive patients (75 ± 3 years, 68% men) with severe symptomatic aortic stenosis referred for surgical aortic valve replacement (SAVR). Preoperatively, patients were tested for bendopnea, which was considered to be present when dyspnoea occurred within 30 s of bending forward. Univariable and stepwise multivariable analyses tested the association of bendopnea with preoperative echocardiographic parameters and postoperative clinical outcomes. RESULTS: Bendopnea was present in 46 of 108 (42%) patients. The mean time of onset was 10.5 ± 3.4 s. Bendopnea was associated with higher estimated pulmonary artery systolic pressures [51 (11) mmHg vs 40 (11) mmHg), P < 0.0001], smaller aortic valve area [0.66 (0.16) cm2 vs 0.76 (0.13) cm2, P = 0.0006] and longer duration of mechanical ventilation (P = 0.002) and length of stay in the hospital (P = 0.007). Following SAVR, in-hospital mortality in those with bendopnea versus those without bendopnea was 13% vs 3% (P = 0.07). In multivariable analysis, bendopnea was associated with duration of mechanical ventilation (parameter estimate 2.4, P < 0.0001) and length of stay in the hospital (parameter estimate 10.2, P ≤ 0.0001). CONCLUSIONS: Bendopnea was present in a sizeable minority of patients (42%) with severe aortic stenosis referred for SAVR. Bendopnea was associated with higher pulmonary artery systolic pressure and smaller aortic valve area preoperatively and with longer duration of mechanical ventilation and length of hospitalization postoperatively. These data suggest that bendopnea provides prognostic information in patients with severe aortic stenosis undergoing SAVR.Sin financiación1.931 JCR (2018) Q2, 96/203 Surgery; Q3, 46/63 Respiratory System, 87/136 Cardiac & Cardiovascular Systems0.763 SJR (2018) Q2, 128/365 Cardiology and Cardiovascular Medicine, 59/152 Pulmonary and Respiratory Medicine, 114/448 SurgeryNo data IDR 2018UE

Contemporary use of cefazolin for MSSA infective endocarditis: analysis of a national prospective cohort

Objectives: This study aimed to assess the real use of cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis (IE) in the Spanish National Endocarditis Database (GAMES) and to compare it with antistaphylococcal penicillin (ASP). Methods: Prospective cohort study with retrospective analysis of a cohort of MSSA IE treated with cloxacillin and/or cefazolin. Outcomes assessed were relapse; intra-hospital, overall, and endocarditis-related mortality; and adverse events. Risk of renal toxicity with each treatment was evaluated separately. Results: We included 631 IE episodes caused by MSSA treated with cloxacillin and/or cefazolin. Antibiotic treatment was cloxacillin, cefazolin, or both in 537 (85%), 57 (9%), and 37 (6%) episodes, respectively. Patients treated with cefazolin had significantly higher rates of comorbidities (median Charlson Index 7, P <0.01) and previous renal failure (57.9%, P <0.01). Patients treated with cloxacillin presented higher rates of septic shock (25%, P = 0.033) and new-onset or worsening renal failure (47.3%, P = 0.024) with significantly higher rates of in-hospital mortality (38.5%, P = 0.017). One-year IE-related mortality and rate of relapses were similar between treatment groups. None of the treatments were identified as risk or protective factors. Conclusion: Our results suggest that cefazolin is a valuable option for the treatment of MSSA IE, without differences in 1-year mortality or relapses compared with cloxacillin, and might be considered equally effective