Early results of a simplified protocol over standard in patients undergoing transcatheter aortic-valve replacement

Introduction

Transcatheter aortic-valve replacement (TAVR) procedure has been simplified, being now a less-invasive minimalist strategy the standard of treatment. Therefore, length of hospitalization has decreased, and early-discharge (ED) (<72 hour) protocols are in development.

Lately, additional techniques to optimize TAVR procedure have arisen, such as the use of radial approach as the secondary access, conscious sedation, cusp overlap projection (COP) to better control the implantation depth in self-expanding (SE) valves, or atrial pacing (AP) after deployment to test atrioventricular (AV) conduction. With the combination of these 4 maneuvers, we have developed an ED protocol, and hereby present the immediate results.

Methods

We prospectively studied 176 patients who underwent staged and transfemoral TAVR procedure with our novel protocol between May 2020 and December 2021 (Protocol) and compared them with a retrospective cohort of 175 patients who underwent standard TAVR between January 2018 and April 2020 (Standard). The protocol cohort included the use of conscious sedation with midazolam and fentanyl, routine radial approach as the secondary access, use of the CO projection, and AP after deployment in the absence of complete AV block, at rates of 70 to 120 beats/min (or until AV Block was observed) in 10 beats/min increments for a total of 20 beats at each increment. As part of this protocol, patients remained in general cardiology ward, avoiding ICU stay, with rapid recovery and early mobilization (After 6 hours in the absence of bleeding). In the absence of complications patients were discharged within 24–48 hours and reviewed a week and a month later in clinic. Initial assessment included EKG, echocardiogram, in hospital and 30-day follow-up.

Results

Median patient age was 80 years old and 49.9% were female. Despite higher rates of hypertension in the standard cohort (p=0.038), no significant differences could be appreciated in baseline demographics, EKG or imaging findings (Table).

Even with higher rates of predilation, CO and AP, the length of procedure and the use of contrast was lower in the protocol cohort. Rates of intraprocedural AV block were similar among groups (p=p.21), but AP led to a significant lower need of temporary pacemaker surveillance (p<0.0001). The use of radial access also tend to diminish immediate bleeding and vascular complications.

According to protocol, the median length of stay was reduced to 2 [1; 4] days (p<0.0001).

At a 30-day follow up, the incidence of major adverse cardiac events was low and similar among groups (p=0.67) (Figure), with no significant differences in the incidence of permanent pacemaker implantation, heart failure admission, bleeding o vascular complication (Figure)

Conclusion

A simplified TAVR protocol combining radial access, CO, AP can be adopted safely, leading to TAVR patients early discharge, with no major events on an immediate 30-day follow-up.

Funding Acknowledgement

Type of funding sources: None.

Clinical value of morphine, pholcodine and poppy seed IgE assays in drug-abusers and allergic people

BACKGROUND

The diagnosis of anaphylactic reactions due to opiates during anaesthesia can be difficult, since in most cases various drugs may have been administered. Detection of specific IgE to poppy seed might be a marker for sensitisation to opiates in allergic people and heroin-abusers. This study assessed the clinical value of morphine, pholcodine and poppy seed skin-prick and IgE determination in people suffering hypersensitivity reactions during anaesthesia or analgesia and drug-abusers with allergic symptoms.

METHODS

We selected heroin abusers and patients who suffered severe reactions during anaesthesia and analgesia from a database of 23,873 patients. The diagnostic yield (sensitivity, specificity and predictive value) of prick and IgE tests in determining opiate allergy was analysed.

RESULTS

Overall, 149 patients and 200 controls, mean age 32.9 ± 14.7 years, were included. All patients with positive prick to opiates showed positive prick and IgE to poppy seeds, but not to morphine or pholcodine IgE. Among drug-abusers, 13/42 patients (31%) presented opium hypersensitivity confirmed by challenge tests. Among non-drug abusers, sensitisation to opiates was higher in people allergic to tobacco (25%), P<.001. Prick tests and IgE against poppy seed had a good sensitivity (95.6% and 82.6%, respectively) and specificity (98.5% and 100%, respectively) in the diagnosis of opiate allergy.

CONCLUSIONS

Opiates may be significant allergens. Drug-abusers and people sensitised to tobacco are at risk. Both the prick and specific IgE tests efficiently detected sensitisation to opiates. The highest levels were related to more-severe clinical profiles.

Allergic hypersensitivity to cannabis in patients with allergy and illicit drug users

BACKGROUND

Cannabis is the illicit drug most widely used by young people in high-income countries. Allergy symptoms have only occasionally been reported as one of the adverse health effects of cannabis use.

OBJECTIVES

To study IgE-mediated response to cannabis in drug users, atopic patients, and healthy controls.

METHODS

Asthmatic patients sensitised to pollen, and all patients sensitised to tobacco, tomato and latex, considered as cross-reacting allergens, were selected from a data base of 21,582 patients. Drug users attending a drug-rehabilitation clinic were also included. Controls were 200 non-atopic blood donors. Specific IgE determination, prick tests and specific challenge with cannabis extracts were performed in patients and controls.

RESULTS

Overall, 340 patients, mean age 26.9±10.7 years, were included. Males (61.4%) were the most sensitised to cannabis (p<0.001). All cannabis-sensitised patients were alcohol users. Eighteen (72%) of the patients allergic to tomato were sensitised to cannabis, but a positive specific challenge to cannabis was highest in patients sensitised to tobacco (13/21, 61.9%), (p<0.001). Pollen allergy was not a risk factor for cannabis sensitisation. Prick tests and IgE for cannabis had a good sensitivity (92 and 88.1%, respectively) and specificity (87.1 and 96%) for cannabis sensitisation.

CONCLUSIONS

Cannabis may be an important allergen in young people. Patients previously sensitised to tobacco or tomato are at risk. Cannabis prick tests and IgE were useful in detecting sensitisation.

Nasopharyngeal aspirate cytokine levels 1 yr after severe respiratory syncytial virus infection

Respiratory syncytial virus (RSV) infection is an important cause of recurrent wheezing in infants. Nevertheless, the link between RSV infection and wheezing has yet to be elucidated at the molecular level. Here, we present a preliminary study on the evolution of the immune response in the respiratory tract at long-term after RSV infection. Twenty-seven immune mediators were profiled in nasopharyngeal aspirates (NPAs) obtained from 20 children hospitalized due to a severe infection by RSV at discharge from hospital and again 1 yr later. The same mediators were profiled in parallel in NPAs from 12 healthy controls. In the year following discharge, 85% (17/20) of children of the RSV group suffered at least one episode of wheezing documented by the pediatrician. On the contrary, wheezing episodes were observed only in 25% (3/12) of children in the control group. While most of the mediators profiled returned to normal levels by 1 yr after discharge from hospital, RSV children showed a persistent nasal hyper-secretion of VEGF, G-CSF, IL-10, IL-6, IFN-gamma, IL-7 and IL-13. In previous works VEGF, IL-10 and IFN-gamma have been put in relation with the pathogenesis of post-virus induced asthma. G-CSF, IL-6, IL-7 and IL-13 are increased in respiratory and plasma samples of asthmatic patients. Here, we evidence for the first time a persistent elevation of these mediators as late as 1 yr after severe RSV disease resolution, reinforcing their possible implication in the pathogenesis of wheezing.

Why can patients with baker's asthma tolerate wheat flour ingestion? Is wheat pollen allergy relevant?

Diagnosis in patients sensitised to multiple pollens is difficult due to the relationship between pollen and food allergens. Misdiagnosis is often a cause for unsuccessful specific immunotherapy. Wheat is a potent allergen source and is one of the causes of baker's asthma, food and pollen allergy. Recently, we have performed a study on pollen sensitisation in our area, where cereal crops are very important. The clinical data from 19718 patients reviewed showed that grass pollen was the main source of clinical symptoms (6369 patients, 32.30% of asthmatics). However, wheat and cereal crop pollen showed very low prevalence. On the other hand, patients with wheat flour allergy after ingestion and/or with baker's asthma were not sensitised to wheat pollen, despite it containing some common allergens. In the same way, all our asthmatic bakers (135 patients) tolerated the ingestion of bread. Here we try to explain the reason for these surprising observations.

[Central venous pressure, rewarming time, and total fluid replacement volume are predictors of mortality and complications after cardiac surgery]

OBJECTIVE

To analyze the influence of early (first day) postoperative factors on postoperative course in patients who have undergone heart surgery.

PATIENTS AND METHODS

A cross-sectional study of consecutively enrolled heart surgery patients was designed. We recorded central venous pressure, time required for rewarming to a core temperature of 35.5degrees C, and total fluids administered in 24 hours. We then analyzed their influence on mortality and cardiac, pulmonary, and renal complications.

RESULTS

Two hundred thirty-six patients were included. Central venous pressure over 18 mm Hg, time to rewarming over 6 hours, and administration of more than 5 L of fluids in the first 24 hours were factors associated with increased mortality and the development of cardiovascular, pulmonary, and renal complications.

CONCLUSIONS

Central venous pressure, rewarming time, and fluid replacement volume required on the first day are predictors of postoperative course.

The inflammatory response to colloids and crystalloids used for pump priming during cardiopulmonary bypass

BACKGROUND

Systemic inflammatory response frequently occurs after coronary artery bypass surgery and is strongly correlated with the risk of postoperative morbidity and mortality. This study tests the hypothesis that the priming of the extracorporeal circuit with colloid solutions results in less inflammation in patients undergoing cardiac surgery than priming with crystalloid solutions.

METHODS

A prospective, randomized study was designed. Forty-four patients undergoing elective coronary artery bypass grafting were randomly allocated to one of two groups: 22 patients primed with Ringer's lactate (RL) solution and 22 patients primed with gelatin-containing solution during the surgery. Plasma levels of interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP) and, complement 4 were measured during the surgical intervention and over the following 48 postoperative hours. Cytokine levels were measured by enzyme-linked assays from plasma samples obtained at specific time points pre- and post-operatively.

RESULTS

In both groups the serum levels of the pro-inflammatory cytokines (IL-6, IL-8, TNF-alpha), CRP, complement 4, and leukocytes increased significantly over the baseline, although no significant differences were observed between the two groups. The operation time, blood loss, need for inotropic support, extubation time, and length of intensive care unit stay did not differ significantly between the two groups.

CONCLUSION

Priming with gelatin vs. RL produces no significant differences in the inflammatory response in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

Tularaemia outbreak in Castilla y León, Spain, 2007: an update

Binary file ES_Abstracts_Final_ECDC.txt matches

Outbreak of tularaemia in Castilla y León, Spain

In late June 2007, the Epidemiological Surveillance Network in Castilla y León, northern Spain, reported a series of cases in a rural area in the province of Palencia and in the provincial capital city of León, labelled as “fever of unknown origin”. Subsequent epidemiological investigation confirmed an outbreak of tularaemia.

Rotavirus in Spain (2000-2004): a predictive model for a surveillance system

Rotavirus infection is one of the main causes of acute gastroenteritis and has an important impact on hospitalisation. There is no homogeneous surveillance system for rotavirus infections in Europe. The aim of this study is to develop a predictive model in order to estimate the expected rotavirus infections in the population covered by a hospital. A five year study (2000-2004) was developed in a Spanish university hospital. A correlation test between the notifications reported to the Microbiological Information System (SIM) and hospitalisations was carried out, as well as a time series analysis, obtaining the trend and the cyclical components. The predictive model was adjusted using the least squares method. A direct relationship between the microbiological isolations and the hospitalisations was established (=0.925; p&lt;0.001). A significant annual cycle was observed, with the peak of cases occurring in February. The two principal outbreaks that occurred in the study period would have been detected with the predictive model. Expected rotavirus cases and hospitalisations for 2005 and 2006 were obtained. The notifications of rotavirus infections reported to SIM are adequate in order to establish a hospital surveillance system, but a predictive model which provides expected cases is also necessary. Therefore, this tool will be useful to evaluate preventive measures such as rotavirus vaccines, which will soon be available in Europe.

Prick-test evaluation to anaesthetics in patients attending a general allergy clinic

BACKGROUND AND OBJECTIVES

To analyse the prevalence of positive prick-tests to all medicaments normally checked in allergy units when a patient is suspected of being allergic to anaesthetics. To establish the degree of agreement between the antecedents of a previous history of an allergic reaction to a medicament and the positive result, or not, to the specific prick-test for the said medicament.

METHODS

This was a prospective study, during 2003 and 2004, which analysed 473 patients referred by their doctors to allergy units to make retrospective diagnoses of an allergy to a drug. The prick-test was done using the undiluted drug. All patients were tested for 41 drugs. These include antibiotics, trimethoprim-sulphamethoxazole, non-steroidal anti-inflammatory drugs (NSAIDs) and perioperative drugs (PD): neuromuscular blocking drugs, latex, iodine, local anaesthetics, hypnotics, opioids and coadjuvants. Cohen's Kappa Index was used to determine the degree of agreement.

RESULTS

71.5% of patients studied presented a positive prick-test. The largest number of positive cases was found in antibiotics (56.4%), followed by PD (15.6%), NSAIDs (14.4%) and trimethoprim-sulphamethoxazole (12.7%). Among PD, the highest prevalence of positive prick-tests was found for neuromuscular blocking drugs (5.3%). Agreement between the substance suspected of causing the allergic reaction and the positive prick-test was excellent for penicillin (Kappa = 0.74) and other antibiotics (Kappa = 0.721) and good for NSAIDs (Kappa = 0.47) and iodine (Kappa = 0.54).

CONCLUSIONS

The prevalence of patients with positive prick-tests to PD occurred in 15.6% in this prospective cohort. Neuromuscular blocking drugs were found to have the highest prevalence of positive prick-tests. There is positive agreement when the substance responsible for the allergic reaction is suspected, otherwise agreement is low.

Prevalence of positive prick test to anaesthetic drugs in the surgical population

Prevalence of patients with positive prick tests to anaesthetics occurred in 4.7% of the surgical population.

[Postoperative analgesia in cardiac surgery: spinal versus intravenous morphine]

OBJECTIVE

To compare the effects of spinal and intravenous administration of morphine to supplement anesthesia with remifentanil in terms of analgesia during early postoperative recovery and considering time until extubation.

MATERIAL AND METHODS

This prospective, randomized, blinded trial enrolled 59 patients scheduled for cardiac surgery. The patients were assigned to receive either a spinal infusion of morphine (15 microg x Kg(-1)) or an intravenous infusion (0.3 mg x Kg(-1)). Anesthesia was maintained with 0.15 to 0.50 microg x Kg(-1) x min(-1) of remifentanil and 2 to 4 mg x Kg(-1) x h(-1) of propofol in perfusion. After the period of extracorporeal circulation, all patients were given an intravenous infusion of 30 mg of ketorolac. Later intravenous ketorolac was ministered at a dose of 30 mg per 8 hours; intravenous morphine (bolus dose of 3 mg) was also administered until pain was relieved.

RESULTS

The same quality of postoperative analgesia and anesthetic recovery was achieved with both spinal and intravenous administration. The incidence of side effects was also similar. Likewise, the extubation times were similar in the 2 groups (spinal infusion group: 294.5 [SD, 150.5] minutes; intravenous group: 325.0 [139.9] minutes; P>0.05). Less postoperative intravenous morphine was administered in the first 24 hours to patients in the spinal morphine group (P<0.05) and fewer patients in that group required intravenous morphine boluses (P<0.05).

CONCLUSIONS

Our study suggests that spinal morphine does not offer advantages over intravenous morphine with regard to postoperative analgesia, hemodynamic stability and respiratory parameters, time until extubation, or adverse effects.

Cereal-induced anaphylaxis in an adult after eating a baby cereal formula

Ingestion of infant cereal formula as a cause of anaphylaxis has been exclusively described in children. We report the case of a man who experienced an anaphylactic reaction after eating his son's cereal formula. We believe that cereals constitute a rising problem and a hidden allergen that can cause severe reactions. Although these reactions are not fully understood, they may possibly be a life-long event.

[Antiretroviral therapy from 1996-2000]

A retrospective study was carried out from September 1996 to June 2000 and examined the antiretroviral therapies prescribed to HIV patients in whom the viral load had been determined. Triple therapy was the most frequently prescribed during the study and the annual percentage increased to 60% in the last semesters analyzed. Large variability in antiretroviral combinations was observed and depended on the clinical center and unit. The number of individuals who began viral-load monitoring before being treated with antiretroviral drugs showed a progressive increase.

Venographic comparison of subcutaneous low-molecular weight heparin with oral anticoagulant therapy in the long-term treatment of deep venous thrombosis

PURPOSE

The primary objective of this study was to evaluate with venography the rate of thrombus regression after a fixed dose of low-molecular weight heparin (LMWH) per day for 3 months compared with oral anticoagulant therapy for deep venous thrombosis (DVT). Secondary endpoints were the comparisons of the efficacy and safety of both treatments.

METHODS

This study was designed as an open randomized clinical study in a university hospital setting. Of the 165 patients finally enrolled in the study, 85 were assigned LMWH therapy and 80 were assigned oral anticoagulant therapy. In the group randomized to oral anticoagulant therapy, the patients first underwent treatment in the hospital with standard unfractionated heparin and then coumarin for 3 months. Doses were adjusted with laboratory monitoring to maintain the international normalized ratio between 2.0 and 3.0. Patients in the LMWH group were administered subcutaneous injections of fixed doses of 40 mg enoxaparin (4000 anti-Xa units) every 12 hours for 7 days, and after discharge from the hospital, they were administered 40 mg enoxaparin once daily at fixed doses for 3 months without a laboratory control assay. A quantitative venographic score (Marder score) was used to assess the extent of the venous thrombosis, with 0 points indicating no DVT and 40 points indicating total occlusion of all deep veins. The rate of thrombus reduction was defined as the difference in quantitative venographic scores after termination of LMWH or coumarin therapy as compared with the scores obtained on the initial venographic results. The efficacy was defined as the ability to prevent symptomatic extension or recurrence of venous thromboembolism (documented with venograms or serial lung scans). The safety was defined as the occurrence of hemorrhages.

RESULTS

After 3 months of treatment, the mean Marder score was significantly decreased in both groups in comparison with the baseline score, although the effect of therapy was significantly better after LMWH therapy (49.4% reduction) than after coumarin therapy (24.5% reduction; P <.001). LMWH therapy and male gender were independently associated with an enhanced resolution of the thrombus. A lower frequency of symptomatic recurrent venous thromboembolism was also shown in patients who underwent treatment with LMWH therapy (9.5%) than with oral anticoagulant therapy (23.7%; P <.05), although this difference was entirely a result of recurrence of DVT. Bleeding complications were significantly fewer in the LMWH group than in the coumarin group (1. 1% vs 10%; P <.05). This difference was caused by minor hemorrhages. Coumarin therapy and cancer were independently associated with an enhanced risk of complications. Subcutaneous heparin therapy was well tolerated by all patients.

CONCLUSION

The patients who were allocated to undergo enoxaparin therapy had a significantly greater improvement in their quantitative venographic score, a significantly lower recurrence rate of symptomatic venous thromboembolism, and a significantly lower incidence of bleeding than patients who underwent treatment with coumarin. LMWH can be used on an outpatient basis as a safer and more effective alternative to classical oral anticoagulant therapy for the secondary prophylaxis of selected patients with DVT.

Early complications in surgical treatment of lung cancer: a prospective, multicenter study. Grupo Cooperativo de Carcinoma Broncogénico de la Sociedad Española de Neumología y Cirugía Torácica

BACKGROUND

We prospectively analyzed the postoperative morbidity, mortality rate, and risk factors in 605 patients who underwent thoracotomy for bronchogenic carcinoma.

METHODS

Patients were categorized by postsurgical tumor stage: I, 287 patients (47.4%); II, 49 patients (8.1%); IIIA, 154 patients (25.5%); IIIB, 80 patients (13.2%); IV, 16 patients (2.7%); unavailable, 19 patients (3.1%). Two hundred ninety-four patients (48.6%) underwent lobectomy, 172 (28.4%) pneumonectomy, 20 (3.3%) bilobectomy, 29 (4.8%) segmentectomy, 27 (4.5%) wedge resection, and 63 (10.4%) exploratory thoracotomy. The importance of the factors that influence the morbidity and mortality rates was calculated from their relative risks. Univariate and multivariate methods for a logistic regression model were used for this analysis.

RESULTS

Postoperative complications developed in 196 patients (32.4%); there were 165 (27.3%) cases of operation-related complications and 152 (25.1%) cases of respiratory and cardiovascular complications. The morbidity rate was highest in patients with preexisting vascular disease (50.9%; odds ratio [OR], 2.20) or insulin-dependent diabetes mellitus (52.4%; OR, 2.77) and in patients who underwent pneumonectomy (40.1%; OR, 1.82). Forty patients (6.6%) died postoperatively, most commonly of respiratory failure (67.5%). The mortality rate was highest in patients with postoperative morbidity (OR, 31.9) or vascular disease (15.8%; OR, 2.83) and in patients who underwent pneumonectomy (13.4%; OR, 4.9).

CONCLUSIONS

Postoperative complications are more likely to develop in patients with peripheral vascular disease or insulin-dependent diabetes mellitus, or both. Postoperative mortality was found to be significantly higher in patients with vascular disease and those who underwent pneumonectomy.

[HIV antibodies in a hospital emergency unit. Detection through a system of pooled batches]

In order to determine the frequency of HIV seropositivity of sera from patients attending our hospital emergency department (ED) we used a HIV screening system based on the use of pooled sera. To determine the reliability of this marker we collect all ED serum samples during two different intervals of a week. From 577 sera analyzed by this method we detected 1.38% of HIV positive samples (95% confidence interval from 0.43% to 2.33%) with 74% benefit on reactives. We did not find significative differences between the rates of HIV seropositivity in the two period of analyzing (1.6% in October 1990 vs 1.2% in February 1991). The consistency of this method for anonymous HIV testing could be applied to a large number of samples from cohorts of expected low HIV prevalence rates and indirectly using this marker to control the spreading of HIV in a given population.