Risk factors for developing ventilator-associated lower respiratory tract infection in patients with severe COVID-19:a multinational, multicentre study, prospective, observational study

Around one-third of patients diagnosed with COVID-19 develop a severe illness that requires admission to the Intensive Care Unit (ICU). In clinical practice, clinicians have learned that patients admitted to the ICU due to severe COVID-19 frequently develop ventilator-associated lower respiratory tract infections (VA-LRTI). This study aims to describe the clinical characteristics, the factors associated with VA-LRTI, and its impact on clinical outcomes in patients with severe COVID-19. This was a multicentre, observational cohort study conducted in ten countries in Latin America and Europe. We included patients with confirmed rtPCR for SARS-CoV-2 requiring ICU admission and endotracheal intubation. Only patients with a microbiological and clinical diagnosis of VA-LRTI were included. Multivariate Logistic regression analyses and Random Forest were conducted to determine the risk factors for VA-LRTI and its clinical impact in patients with severe COVID-19. In our study cohort of 3287 patients, VA-LRTI was diagnosed in 28.8% [948/3287]. The cumulative incidence of ventilator-associated pneumonia (VAP) was 18.6% [610/3287], followed by ventilator-associated tracheobronchitis (VAT) 10.3% [338/3287]. A total of 1252 bacteria species were isolated. The most frequently isolated pathogens were Pseudomonas aeruginosa (21.2% [266/1252]), followed by Klebsiella pneumoniae (19.1% [239/1252]) and Staphylococcus aureus (15.5% [194/1,252]). The factors independently associated with the development of VA-LRTI were prolonged stay under invasive mechanical ventilation, AKI during ICU stay, and the number of comorbidities. Regarding the clinical impact of VA-LRTI, patients with VAP had an increased risk of hospital mortality (OR [95% CI] of 1.81 [1.40-2.34]), while VAT was not associated with increased hospital mortality (OR [95% CI] of 1.34 [0.98-1.83]). VA-LRTI, often with difficult-to-treat bacteria, is frequent in patients admitted to the ICU due to severe COVID-19 and is associated with worse clinical outcomes, including higher mortality. Identifying risk factors for VA-LRTI might allow the early patient diagnosis to improve clinical outcomes. Trial registration: This is a prospective observational study; therefore, no health care interventions were applied to participants, and trial registration is not applicable

Characterization of patients with gastric and gastroesophageal junction adenocarcinoma advanced and metastatic in the Hospital Militar Central between 2015 and 2021

Introducción: El cáncer gástrico es una de las neoplasias más frecuentes en el mundo, en nuestro país, ocupa el cuarto lugar en frecuencia y constituye el segundo tumor maligno más común en hombres con una alta tasa de progresión y de mortalidad (9) (1). En etapas avanzadas, la supervivencia a 5 años continúa siendo pobre, aproximadamente el 5-10 % de los casos.(11) (12) Teniendo en cuenta la problemática en salud pública que constituye el cáncer gástrico en varios grupos etáreos, se planteó la importancia de caracterizar a los pacientes con adenocarcinoma gástrico y de la unión gastroesofágica avanzada y describir la sobrevida posterior al tratamiento con quimioterapia de primera línea con fines paliativos. Objetivo: Caracterizar a los pacientes con adenocarcinoma gástrico y de la unión gastroesofágica avanzado y metastásico sometidos a primera línea de quimioterapia en el Hospital Militar Central entre 2015 y 2021. Materiales y métodos: Estudio observacional analítico de una cohorte dinámica de pacientes adultos con diagnóstico de adenocarcinoma gástrico atendidos en el Hospital Militar Central. Resultados: Se revisaron 219 historias correspondientes a pacientes mayores de 18 años con diagnóstico de adenocarcinoma gástrico atendidos en el Hospital Militar Central entre el 2015 y el 2021, el sexo masculino (72,6%) fue el que predominante en el grupo estudiado. Dentro de los subgrupos de edad, el 46.57% tenia entre 60 y 79 años. Al momento del diagnóstico cerca a la mitad de pacientes (49.32%) presentaba estadificación clínica IV, seguidos de un 26.03% de pacientes con estadio III. Del total de la población, el 58.9% pacientes fueron sometidos a quimioterapia de primera línea con intención paliativa. De los pacientes que se encontraban en estadio IV 25.7% sobrevivió al primer año y 6% al segundo año. Conclusión. A partir de la caracterización de la población con adenocarcinoma gástrico avanzado y metastásico se resalta la importancia de implementar sistemáticamente estrategias de prevención y diagnóstico temprano y la realización rutinaria en todos los pacientes con diagnóstico de cáncer gástrico de marcadores moleculares. Este estudio abre la puerta para la realización de investigaciones posteriores que permita estimar la supervivencia global y por subgrupos, esclarecer las variables implicadas con mal pronóstico y dar aplicación de los resultados actuales y los posteriores en la práctica clínica.1.Resumen 8 2.Marco teórico 9 3.Identificación y formulación del problema 24 4. Justificación 26 5. Objetivos 27 5.1 Objetivo general 27 5.2 Objetivos específicos 27 6. Metodología 29 6.1 Tipo y diseño general del estudio 29 6.2 Población 29 6.2.1 Población referencia 29 6.2.2 Población blanco 29 6.2.3 Población estudio 30 6.3 Criterios de inclusión y exclusión 30 6.3.1 Inclusión 30 6.3.2 Exclusión 31 6.4 Diseño muestral 31 6.5 Tamaño de la muestra 31 7. Definición de las variables 33 8. Plan de análisis 40 8.1 Fuentes de información 40 8.2 Instrumentos de recolección de la información 40 8.3 Procesamiento obtención información 40 8.4 Estrategias para suprimir amenazas 41 8.4.1 Control sesgos y errores 35 8.5 Análisis estadístico 35 9. Cronograma 43 10. Presupuesto 45 11. Aspectos éticos 46 12. Resultados 48 13. Discusión 65 14. Conclusiones 72 15. Referencias bibliográficas 74 16. Trayectoria de los investigadores 81 17. Anexos 93Introduction: Gastric cancer is one of the most common neoplasms in the world, in our country, it ranks fourth in frequency and is the second most common malignant tumor in men with a high rate of progression and mortality (9) (1). In advanced stages, 5-year survival continues to be poor, approximately 5-10% of cases.(11) (12) Taking into account the public health problem that gastric cancer constitutes in various age groups, the importance of characterizing patients with advanced gastric and gastroesophageal junction adenocarcinoma and describing survival after treatment with first-line chemotherapy for palliative purposes was considered. Objective: To characterize patients with advanced and metastatic gastric and gastroesophageal junction adenocarcinoma undergoing first-line chemotherapy at the Hospital Militar Central between 2015 and 2021. Methodology: Observational analytical study of a dynamic cohort of adult patients diagnosed with gastric adenocarcinoma treated at the Central Military Hospital was carried out. Results: 219 records corresponding to patients older than 18 years with a diagnosis of gastric adenocarcinoma treated at the Hospital Militar Central between 2015 and 2021 were reviewed, the male sex (72.6%) was the predominant in the group studied. Within the age subgroups, 46.57% were between 60 and 79 years old. At the time of diagnosis, nearly half of the patients (49.32%) presented clinical stage IV, followed by 26.03% of patients with stage III. Of the total population, 58.9% patients underwent first-line chemotherapy with palliative intent. Of the patients who were in stage IV, 25.7% survived the first year and 6% the second year. Conclusions: Based on the characterization of the population with advanced and metastatic gastric adenocarcinoma, the importance of systematically implementing prevention strategies and early diagnosis and routinely performing molecular markers in all patients diagnosed with gastric cancer is highlighted. This study opens the door for further research to estimate overall survival and survival by subgroups, clarify the variables involved in poor prognosis, and apply current and later results in clinical practice.Especializació

Cosechando sueños y memorias: Cuentos y cotidianidades.

El documento completo no se encuentra disponible en acceso abierto (disponible portada y tabla de contenido)

Cosechando sueños y memorias: Cuentos y cotidianidades.

El documento completo no se encuentra disponible en acceso abierto (disponible portada y tabla de contenido)

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Outcomes from elective colorectal cancer surgery during the SARS‐CoV‐2 pandemic

Aim This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic. Method This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2 and a comparison with prepandemic European Society of Coloproctology cohort data. Results From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV-2 (14/1601, 0.9%) and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58–14.06), postoperative SARS-CoV-2 (16.90, 7.86–36.38), male sex (2.46, 1.01–5.93), age >70 years (2.87, 1.32–6.20) and advanced cancer stage (3.43, 1.16–10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%). Conclusion Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative and organizational risks

The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AimThe SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery.MethodsThis was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin.ResultsOverall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P ConclusionOne in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

Delaying surgery for patients with a previous SARS-CoV-2 infection

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