Correlació entre l’hemodinàmica, la morfometria, la histoquímica i l’estat neonatal en un model d’hèrnia diafragmàtica tractada amb oclusió traqueal

[cat] INTRODUCCIÓ: L’hèrnia diafragmàtica congènita (HDC) és una malformació molt greu, amb una mortalitat que supera el 50% de tots els casos. Les causes principals de mort són la hipoplàsia pulmonar i la hipertensió pulmonar persistent. La hipoplàsia pulmonar es deu a un compromís en el desenvolupament del pulmó, que és més petit, té menys ramificacions bronquials i unitats alveolars. La hipertensió pulmonar es produeix perquè el nombre de vasos pulmonars està disminuït, són més gruixuts i muscularitzats i més sensibles als diferents estímuls, com ara la hipoxèmia. Els models animals d’HDC han demostrat que el tractament fetal de la malformació indueix la maduració dels espais aeris i l’estructura vascular del pulmó. Aquests dos efectes, s’assumeix, tindrien lloc en paral·lel. El mal pronòstic de molts fetus amb HDC ha fet que el tractament prenatal de la malformació ja sigui una realitat. L’únic tractament fetal de l’HDC acceptat en aquests moments és l’oclusió traqueal (OT). HIPÒTESIS I OBJECTIU: Aquest treball parteix de la hipòtesi que, en un model d’hèrnia diafragmàtica en conill, el tractament amb OT traqueal tardana reverteix la hipoplàsia pulmonar i disminueix la hipertensió pulmonar que presenten els fetus amb HD no tractats. De forma més concreta pretenem demostrar que en el model d’HD en conill: 1. L’OT tardana millora el tant desenvolupament dels espais aeris com el vascular. En conseqüència, els nounats amb una HD tractada amb OT presentaran una situació neonatal inicial més satisfactòria. 2. Hi ha una correlació entre els valors dels paràmetres morfològics que estimen la hipoplàsia pulmonar, els paràmetres histològics suggestius d’hipertensió pulmonar, les mesures hemodinàmiques sobre els fetus vius i l’avaluació funcional neonatal. MATERIAL I MÈTODE: S’ha emprat el model d’HDC en conill, en què l’HD es crea el dia 23 de gestació i l’OT, el 28 (la gestació del conill dura 31 dies). S’han definit dos grups d’estudi: HD (hèrnia diafragmàtica) i OT (HD tractats amb OT). El dia 30 de gestació es van fer mesures hemodinàmiques de l’artèria pulmonar sobre els fetus vius (índex de pulsatilitat i fracció de sang en moviment). Els animals es recolliren poc després per cesària. S’ha estudiat la morfometria dels pulmons (quocient entre el pes pulmonar i el fetal i recompte alveolar radial) i s’ha mesurat el gruix de la capa muscular de les arterioles. També s’han recollit animals no tractats perquè serveixin com a estàndard de normalitat. RESULTATS: Els animals del grup HD (n=9) tenen els pitjors paràmetres hemodinàmics. Alhora, els seus pulmons són els més hipoplàstics i els que tenen les arterioles més gruixudes. Els animals del grup OT (n=10) reverteixen tots aquests efectes. Llevat d’una correlació entre el recompte alveolar radial (mesura d’hipoplàsia pulmonar) i l’índex de pulsatilitat destaca un patró d’absència de correlació entre les respostes vasculars i de maduració dels espais aeris després de l’OT. CONCLUSIONS: 1. En els fetus amb HD tractada amb OT milloren les característiques del flux vascular pulmonar (disminueixen les resistències i augmenta la perfusió pulmonar); els espais aeris pulmonars maduren; paral·lelament, també s’observa una maduració vascular pulmonar. Per tot plegat, els nounats amb HD sotmesos a OT neixen amb avantatge respecte els que no s’han tractat. 2. L’OT és el gatell que desencadena tots aquests efectes. Hi ha una correlació pobra entre ells, ja que les respostes no són proporcionals entre si. És més, en bona part, es produeixen de forma independent les unes de les altres. El mecanisme subjacent que permet explicar la manca de correlacions ha de ser l’estimulació de vies metabòliques reguladores independents per a la maduració vascular pulmonar, la maduració de les vies respiratòries i potser la resposta hemodinàmica dels vasos pulmonars.[eng] BACKGROUND: In animal models of congenital diaphragmatic hernia (CDH), tracheal occlusion (TO) has induced maturation of both airway spaces and vascular structures. Airway and vascular response to TO are assumed to occur in parallel. This study aims to describe and measure the relationship between airway and vascular maturation induced by TO. MATERIALS AND METHODS: A rabbit model of CDH on gestational day (GD) 23 and TO on GD28 (term=GD31) has been used. Two study groups have been defined: DH (diaphragmatic hernia) and TO (DH treated with TO). Blood flow data of the pulmonary artery (pulsatility index and fractional moving blood volume) were ultrasonographically measured at GD30. Animals were collected on GD30. Lung morphometry consisted of radial alveolar count (RAC) and arterial muscular thickness (AMT). RESULTS: Animals in group DH (n=9) had the worst hemodynamic parameters; their lungs were hypoplastic and had the thickest arterial muscular layer. Animals in group TO (n=10) had reversed all these effects. There were no correlations among hemodynamic, airway and vascular parameters, except for RAC and pulsatility index (r=-0.528, p=0.043). CONCLUSION: Airway and vascular maturation after TO appear to be independent effects. Tracheal occlusion could trigger several pathways that would separately regulate airway and vascular response

Distinguishing outcomes of neonatal intestinal volvulus: review of our experience over the last 20 years

Aim: There are two types of intestinal volvulus: midgut (MGV) and segmental (SV). Patients with different types of intestinal volvulus are often included in the same case series, which may affect the perception of how severe "intestinal volvuli" are. We aimed to compare both types of intestinal volvulus. Methods: This is a retrospective observational study including all patients with MGV and SV up to 28 days of life admitted to a tertiary hospital in Spain over a 20-year-period (1999-2019). A comparison between groups and a logistic regression model for mortality were done. Results: We identified 32 patients: 23 MGV and 9 SV. Malrotation was exclusive of MGV. Prenatal diagnosis, cystic fibrosis, and intestinal resection were significantly more frequent in SV. Surgery was performed at a significantly lower age in SV. The mortality observed in acute MGV with intestinal compromise (41.7%) is four times higher than the mortality of SV (11.1%). The overall mortality of all MGV patients (21.7%) is almost twice that of SV. Mortality was best predicted by the presence of hemodynamic instability (OR 27.5 95% CI 2.50-302.17; p = 0.007). Conclusion: SV and MGV have a different clinical presentation. Hemodynamic instability is the major risk factor for death

Geometries habitables: Bases per al Projecte I - II [BPI - BPII matins]

2020/202

Geometries habitables: Bases per al Projecte I - II [BPI - BPII matins]

2019/202

Geometries habitables: Bases per al Projecte I - II [BPI - BPII matins]

2018/201

Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care