Utilidad de la prueba de esfuerzo en la valoración preoperatoria de pacientes con enfermedad pulmonar obstructiva crónica y neoplasia pulmonar /

Descripció del recurs: 16 gener 2003Consultable des del TDXTítol obtingut de la portada digitalitzadaLa cirugía es el tratamiento de elección de los pacientes con cáncer de pulmón (CP) en estadío resecable. La frecuente coexistencia de la enfermedad pulmonar obstructiva crónica (EPOC) puede contraindicar este tratamiento, que es el único potencialmente curativo. Además, la coexistencia de la EPOC podría empeorar la evolución intraoperatoria de estos pacientes. Se realizaron dos estudios para evaluar la utilidad de la prueba de esfuerzo (PE) cardiopulmonar en la valoración preoperatoria de estos pacientes. El objetivo del primer estudio fue evaluar si la PE invasiva con mediciones hemodinámicas pulmonares y del intercambio de gases podría ser de utilidad en la predicción de la morbilidad y mortalidad tras la cirugía de resección pulmonar en pacientes con EPOC y CP con riesgo quirúrgico incrementado. Se estudiaron de forma prospectiva 65 pacientes antes de la toracotomía con CP y EPOC de moderada-severa intensidad. A todos los pacientes se les realizaron en el periodo preoperatorio pruebas funcionales respiratorias (espirometría, volúmenes pulmonares y capacidad de difusión del monóxido de carbono [DLCO]), una gammagrafía pulmonar de perfusión cuantificada y una PE con medición de gases arteriales en reposo y durante el esfuerzo y, además, mediciones hemodinámicas pulmonares en un subgrupo de 46 pacientes. Aparecieron complicaciones postoperatorias en el 48% de los pacientes y la mortalidad fue únicamente del 6.2%. La única variable predictiva de morbilidad fue el volúmen espiratorio forzado en el primer segundo (FEV1) previsto postoperatorio (ppo). Las variables predictivas de mortalidad fueron el FEV1ppo, la DLCOppo y el empeoramiento del intercambio de gases durante el esfuerzo. Se concluye que los pacientes con CP y EPOC con riesgo quirúrgico incrementado pueden ser operados con una mortalidad aceptable, aunque con una morbilidad elevada, y que un empeoramiento del intercambio de gases durante el esfuerzo implicaría un mayor riesgo de mortalidad entre los pacientes con un FEV1ppo más bajo. Los objetivos del segundo estudio fueron: evaluar la evolución del intercambio de gases y de la hemodinámica pulmonar durante la toracotomía con resección pulmonar en pacientes con CP y EPOC con riesgo quirúrgico incrementado y valorar si alguna variable del estudio preoperatorio (con PE incluida) tiene poder predictivo de eventos adversos intraoperatorios (tanto hemodinámicos como del intercambio de gases). Se estudiaron 40 pacientes con CP y EPOC con riesgo quirúrgico incrementado. El estudio preoperatorio fue idéntico al descrito en el primer estudio. Durante la intervención se realizaron mediciones de gases respiratorios en sangre arterial y venosa mixta, de los parámetros ventilatorios y de hemodinámica pulmonar. Estas mediciones se realizaron tanto durante la ventilación bipulmonar como durante la ventilación unipulmonar (VUP). Durante la cirugía, la instauración de la VUP provocó un marcado deterioro del intercambio de gases, más pronunciado en las toracotomías derechas debido al menor incremento del gasto cardiaco (QT) que acontece tras la apertura del tórax en estos casos, ya que cuando el hemitórax izquierdo se encuentra en posición declive, el corazón sufriría una situación mecánica más desfavorable, que dificultaría el llenado ventricular. Además, la instauración de la VUP provoca un aumento pasivo moderado de la presión arterial pulmonar secundario al incremento del QT, sin que exista un aumento valorable del tono vascular pulmonar. Se concluye que el deterioro del intercambio de gases durante la VUP es más pronunciado en las toracotomías derechas por la influencia de los factores extrapulmonares, especialmente del QT, sobre el intercambio de gases. Los pacientes con una peor oxigenación durante el esfuerzo y con una reducción en la perfusión del pulmón no neoplásico (que es el responsable del intercambio de gases durante la VUP) tienen el máximo riesgo de hipoxemia durante la cirugía.Surgery remains the treatment of choice for patients with resectable lung cancer (LC). However, a significant proportion of patients undergoing lung resections have the associated condition chronic obstructive pulmonary disease (COPD), which increases the risk of perioperative complications and makes surgery unfeasible in some cases. Furthermore, the coexistence of COPD could worsen the intraoperative course of these patients. Two studies have been performed to evaluate the potential role of cardiopulmonary exercise testing (ET) in the preoperative assessment of these patients. The objective of the first study was to investigate if invasive ET with gas exchange and pulmonary hemodynamic measurements could be helpful in the prediction of morbidity and mortality after lung resection in patients with COPD and LC at high-risk. Sixty-five patients with LC and moderate-to-severe COPD were prospectively studied before thoracotomy. Before surgery, all patients underwent pulmonary function testing (spirometry, lung volumes and diffusing capacity of the lung for carbon monoxide [DLCO]), quantitative perfusion pulmonary scintigraphy, and ET with gas exchange measurements at rest and during exercise. Additionally, pulmonary hemodynamic measurements were performed in 46 of the patients. Postoperative complications developed in 48% of the patients, and mortality was only 6.2%. The only variable that was helpful in the prediction of morbidity was forced expiratory volume in one second (FEV1) predicted postoperative (ppo). The variables that were helpful in the prediction of mortality were FEV1ppo, DLCOppo and worsening of gas exchange during exercise. We conclude that patients with COPD and LC at high-risk for lung resection can be operated with an acceptable mortality, though with a high morbidity. Furthermore, worsening of gas exchange during exercise could mean a higher mortality risk among those patients with lower FEV1ppo values. The aims of the second study were: to evaluate the evolution of gas exchange and pulmonary hemodynamics during thoracotomy with lung resection in patients with LC and COPD at increased risk, and to test whether preoperative evaluation (including ET) could be predictive of a worse intraoperative course (either pulmonary hemodynamics or gas exchange). Forty patients with LC and COPD at increased risk were studied. The preoperative evaluation was the same that was performed in the first study. During the surgical procedure the following measurements were performed: arterial and mixed venous respiratory blood gases, ventilatory variables and pulmonary hemodynamics. These measurements were performed during two-lung ventilation and during one-lung ventilation (OLV). During the surgical procedure, the institution of OLV resulted in a marked worsening of gas exchange, that was more pronounced in right thoracotomies due to the lower increase in cardiac output (QT) that takes place after thorax aperture in these patients, as when the left hemithorax is in the dependent position, the heart might suffer a greater compression by the lung, mediastinum and abdominal contents, thereby limiting ventricular filling. Also, the institution of OLV resulted in a moderate increase of pulmonary artery pressure due to the increase in QT, as pulmonary vascular tone was essentially unchanged. We conclude that worsening of gas exchange during OLV is more pronounced in right thoracotomies due to the influence of extrapulmonary factors, specially QT, on gas exchange. Patients with a worse oxygenation during exercise and with a reduction in the perfusion of the non neoplastic lung (that is responsible for gas exchange during OLV) are at the highest risk of hypoxemia during the surgical procedure

Neuromyelitis optica spectrum disorders. Comparison according to the phenotype and serostatus

Objective: To (1) determine the value of the recently proposed criteria of neuromyelitis optica (NMO) spectrum disorder (NMOSD) that unify patients with NMO and those with limited forms (NMO/LF) with aquaporin-4 immunoglobulin G (AQP4-IgG) antibodies; and (2) investigate the clinical significance of the serologic status in patients with NMO. Methods: This was a retrospective, multicenter study of 181 patients fulfilling the 2006 NMO criteria (n = 127) or NMO/LF criteria with AQP4-IgG (n = 54). AQP4-IgG and myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG) antibodies were tested using cell-based assays. Results: Patients were mainly white (86%) and female (ratio 6.5:1) with median age at onset 39 years (range 10-77). Compared to patients with NMO and AQP4-IgG (n = 94), those with NMO/LF presentedmore often with longitudinally extensive transverse myelitis (LETM) (p<0.001), and had lower relapse rates (p = 0.015), but similar disability outcomes. Nonwhite ethnicity and optic neuritis presentation doubled the risk for developing NMO compared with white race (p = 0.008) or LETM presentation (p = 0.008). Nonwhite race (hazard ratio [HR] 4.3, 95% confidence interval [CI] 1.4-13.6) and older age at onset were associated with worse outcome (for every 10-year increase, HR 1.7, 95% CI 1.3-2.2). Patients with NMO and MOG-IgG (n = 9) had lower female: male ratio (0.8:1) and better disability outcome than AQP4-IgG-seropositive or double-seronegative patients (p<0.001). Conclusions: In patients with AQP4-IgG, the similar outcomes regardless of the clinical phenotype support the unified term NMOSD; nonwhite ethnicity and older age at onset are associated with worse outcome. Double-seronegative and AQP4-IgG-seropositive NMO have a similar clinical outcome. The better prognosis of patients with MOG-IgG and NMO suggests that phenotypic and serologic classification is useful

Randomized placebo-controlled phase II trial of autologous mesenchymal stem cells in multiple sclerosis.

OBJECTIVE: Uncontrolled studies of mesenchymal stem cells (MSCs) in multiple sclerosis suggested some beneficial effect. In this randomized, double-blind, placebo-controlled, crossover phase II study we investigated their safety and efficacy in relapsing-remitting multiple sclerosis patients. Efficacy was evaluated in terms of cumulative number of gadolinium-enhancing lesions (GEL) on magnetic resonance imaging (MRI) at 6 months and at the end of the study. METHODS: Patients unresponsive to conventional therapy, defined by at least 1 relapse and/or GEL on MRI scan in past 12 months, disease duration 2 to 10 years and Expanded Disability Status Scale (EDSS) 3.0-6.5 were randomized to receive IV 1-2×10(6) bone-marrow-derived-MSCs/Kg or placebo. After 6 months, the treatment was reversed and patients were followed-up for another 6 months. Secondary endpoints were clinical outcomes (relapses and disability by EDSS and MS Functional Composite), and several brain MRI and optical coherence tomography measures. Immunological tests were explored to assess the immunomodulatory effects. RESULTS: At baseline 9 patients were randomized to receive MSCs (n = 5) or placebo (n = 4). One patient on placebo withdrew after having 3 relapses in the first 5 months. We did not identify any serious adverse events. At 6 months, patients treated with MSCs had a trend to lower mean cumulative number of GEL (3.1, 95% CI = 1.1-8.8 vs 12.3, 95% CI = 4.4-34.5, p = 0.064), and at the end of study to reduced mean GEL (-2.8±5.9 vs 3±5.4, p = 0.075). No significant treatment differences were detected in the secondary endpoints. We observed a non-significant decrease of the frequency of Th1 (CD4+ IFN-γ+) cells in blood of MSCs treated patients. CONCLUSION: Bone-marrow-MSCs are safe and may reduce inflammatory MRI parameters supporting their immunomodulatory properties. ClinicalTrials.gov NCT01228266

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. // Methods: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. // Findings: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. // Interpretation: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Depth records of Ophidion barbatum in western Mediterranean

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Depth records of Ophidion barbatum (Ophidiiformes, Ophidiidae) in Western Mediterranean

Depth records of Ophidion barbatum (Ophidiiformes, Ophidiidae) in western MediterraneanRecord de profondeur de Ophidion barbatum (Ophidiiformes, Ophidiidae) dans la Méditerranée occidental