Sepsis Code: dodging mortality in a tertiary hospital

Introducción

En el hospital de La Princesa comienza el “Código Sepsis” (CSP) en el año 2015, como un grupo multidisciplinar que dota al personal sanitario de herramientas clínicas, analíticas y organizativas, con el objetivo de la detección y el tratamiento precoz del paciente con sepsis. El objetivo de este estudio es evaluar el impacto de la implantación de CSP en la mortalidad y determinar las variables asociadas con un aumento de la misma.

Material y métodos

Se realizó un estudio analítico retrospectivo de los pacientes con activación de la alerta CSP de 2015 a 2018. Se recogieron variables clínico-epidemiológicas, parámetros analíticos y factores de gravedad como el ingreso en Unidades de Cuidados Críticos (UCC) y la necesidad de aminas. La significación estadística se estableció en una p < 0,05.

Resultados

Se incluyeron 1.121 pacientes. La estancia media fue de 16 días y un 32% requirieron ingreso en UCC. La mortalidad mostró una tendencia lineal descendente estadísticamente significativa del 24% en 2015 hasta el 15% en 2018. Las variables predictivas de mortalidad con asociación estadísticamente significativa fueron el lactato > 2 mmol/L, la creatinina > 1,6 mg/dL y la necesidad de aminas.

Conclusiones

La implementación de Código Sepsis disminuye la mortalidad de los pacientes con sepsis y shock séptico. La presencia de una cifra de lactato > 2 mmol/L, los niveles de creatinina > 1,6 mg/dL y/o la necesidad de administrar aminas en las primeras 24 horas, se asocian con un aumento de la mortalidad en el paciente con sepsis.

Respiratory support in COPD patients after acute exacerbation with monitoring the quality of support (Rescue2-monitor): an open-label, prospective randomized, controlled, superiority clinical trial comparing hospital- versus home-based acute non-invasive ventilation for patients with hypercapnic chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is expected to be the 3rd leading cause of death worldwide by 2020. Despite improvements in survival by using acute non-invasive ventilation (NIV) to treat patients with exacerbations of COPD complicated by acute hypercapnic respiratory failure (AHRF), these patients are at high risk of readmission and further life-threatening events, including death. Recent studies suggested that NIV at home can reduce readmissions, but in a small proportion of patients, and with a high level of expertise. Other studies, however, do not show any benefit of home NIV. This could be related to the fact that respiratory failure in patients with stable COPD and their response to mechanical ventilation are influenced by several pathophysiological factors which frequently coexist in the same patient to varying degrees. These pathophysiological factors might influence the success of home NIV in stable COPD, thus long-term NIV specifically adapted to a patient's "phenotype" is likely to improve prognosis, reduce readmission to hospital, and prevent death. In view of this conundrum, Rescue2-monitor (R2M), an open-label, prospective randomized, controlled study performed in patients with hypercapnic COPD post-AHRF, will investigate the impact of the quality of nocturnal NIV on the readmission-free survival. The primary objective is to show that any of 3 home NIV strategies ("rescue," "non-targeted," and "targeted") will improve readmission-free survival in comparison to no-home NIV. The "targeted" group of patients will receive a treatment with personalized (targeted) ventilation settings and extensive monitoring. Furthermore, the influence of comorbidities typical for COPD patients, such as cardiac insufficiency, OSA, or associated asthma, on ventilation outcomes will be taken into consideration and reasons for non-inclusion of patients will be recorded in order to evaluate the percentage of ventilated COPD patients that are screening failures. ClinicalTrials.gov NCT03890224 . Registered on March 26, 2019.

Catchment based hydrology under post farmland abandonment scenarios

Vegetation expansion following farmland abandonment is a complex process that depends on multiple natural and human-induced factors, resulting in differences in the evolution of land cover on former cultivated fields, with various environmental implications. To assess the complexity of the hydrogeomorphological consequences of farmland abandonment, the Instituto Pirenaico de Ecología (CSIC) and the University of La Rioja monitored three small catchments, representative of different post land abandonment scenarios, in the Pyrenees and Iberian Range respectively. In the Pyrenees, a fourth small catchment, covered by natural forest, was monitored as a reference for an undisturbed environment. This study describes the evolution of land use in the abandoned catchments and examines its implications on catchment hydrological connectivity. It also analyses the hydrological responses of the three abandoned scenarios to similar rainfall events, and compares them to that of natural forested areas. .Vegetation tended to increase in the three catchments, but there were important differences in the characteristics of the current land cover. Arnás, the catchment left to a process of natural revegetation, contained a mosaic of shrubs (64%) and forest (27%) at different stages of succession, largely conditioned by the topography and soil properties. Araguás_afforestation was extensively afforested in the 1960s, with 75% of this catchment currently covered by forest, most of it planted artificially. In Munilla, occupied by terraced fields, vegetation recovery was partly restrained by the introduction of cattle, and 80% of the catchment was covered by sparse shrubs. Land abandonment resulted in a general reduction in computed hydrological connectivity in the three studied catchments, except in localized areas close to the main channel, new forest roads and trails, and upstream of terrace wall collapses, all areas of increased hydrological connectivity. The decrease in hydrological connectivity was much lower in Munilla, characterized by an absence of dense vegetation and still dominated by a terraced topography. The hydrological responses of the catchments to similar rainfall events differed significantly, showing the influence of not only vegetation cover but of the properties of soil remaining after previous agricultural activities. Significant storm-flow discharge was observed in Arnás, even under dry conditions, with high peakflows and fast responses. Lower streamflow response was observed in Araguás_Afforestation under dry conditions; however, once the soils were wet the hydrological response was notable and was characterized by high peakflow. The response under afforested trees differed greatly from that of a catchment covered by natural forest, with the latter characterized by gentler hydrographs. The hydrological response in Munilla was the lowest, with long response times and recessions, associated with the thick soils of the terraced fields. These results demonstrated the large variability of post land abandonment scenarios and associated hydrological implications, and highlighted the need to consider these differences to reduce future uncertainties in forecasting water resources and soil conservation.

Mass soil movement on terraced landscapes of the Mediterranean mountain areas: a case study of the Iberian Range, Spain

Terraces represent one of the most common agricultural landscapes in Mediterranean mountainous regions. However, the demographic and socioeconomic changes occurring in the second half of the last century caused terraces abandonment, leading to the loss of maintenance work required by these agricultural structures, and promoting various erosion processes, in particular the collapse of stone walls and small slides in risers. This paper analyses these mass movements by quantifying their size and frequency and defining the variables involved in their triggering in the upper valleys of Leza, Jubera and Cidacos rivers (Camero Viejo, Iberian Range, Spain), where bench terraces occupied 13,274 hectares (63% of agricultural space). A total amount of 240 small slides were recorded in 53 terraces studied, which means an average of 4.5 slides per plot and 33.1 m3 of material mobilized per 100 m of wall. This study proves that the most decisive causes for slides to start are related to soil infiltration capacity, as well as to the way in which water runs down the hillside.

Respiratory Disorders and Quality of Sleep in Patients on the Waiting List for Lung Transplantation

BACKGROUND

The purpose of this study was to assess the quality of sleep and extent of respiratory disorders in patients awaiting lung transplantation as compared with a control group.

METHODS

From September 2003 to November 2003, 17 clinically stable patients on the waiting list for lung transplantation and 14 healthy controls (with similar age, gender, and body mass index) were studied. Diagnostic polysomnography (PSG) was carried out for all subjects.

RESULTS

Seventeen patients were included, 15 men and 2 women, aged 51 +/- 14 years. The indication for lung transplantation was emphysema in 7 cases, pulmonary fibrosis in 6, and "other" in 4. Patients awaiting lung transplantation had the following respiratory values: mean FEV1, 1105 mL (34% of predicted); PaO2, 54 mm Hg; and PaCO2, 44 mm Hg. Significant differences were found among the waiting-list patients in terms of predominance of light sleep, wakeful periods, and phase changes per sleep-hour, as compared with the control group. The recording of the respiratory events showed an apnea-hypopnea index of 6.13, sleeping time with SaO2 <90% of 1.80%, and a mean number of significant desaturations (<4%) of 6.38. There were no statistically significant differences with respect to the control group.

CONCLUSIONS

Poor quality of sleep was observed in patients awaiting lung transplantation as compared with a healthy control group. There was no evidence of more respiratory events or significant desaturations in these patients, probably due to the provision of supplementary oxygen therapy during the PSG.

Quantity does matter. Juvenile hormone and the onset of vitellogenesis in the German cockroach

We aimed to elucidate why cockroaches do not produce vitellogenin in immature stages, by studying the appearance of vitellogenin mRNA in larvae of Blattella germanica. Treatment of female larvae in any of the last three instars with 1 microg of juvenile hormone (JH) III induces vitellogenin gene transcription, which indicates that the fat body is competent to transcribe vitellogenin at least from the antepenultimate instar larvae. In untreated females, vitellogenin production starts on day 1 after the imaginal molt, when corpora allata begin to synthesize JH III at rates doubling the maximal of larval stages. This coincidence suggests that the female reaches the threshold of JH production necessary to induce vitellogenin synthesis on day 1 of adult life. These data lead to postulate that larvae do not synthesize vitellogenin simply because they do not produce enough JH, not because their fat body is incompetent.

Screening of antifeedant activity in brain extracts led to the identification of sulfakinin as a satiety promoter in the German cockroach. Are arthropod sulfakinins homologous to vertebrate gastrins-cholecystokinins?

The feeding cycle of the adult female cockroach Blattella germanica parallels vitellogenesis. The study of the mechanisms that regulate this cycle led us to look for food-intake inhibitors in brain extracts. The antifeedant activity of brain extracts was tested in vivo by injecting the extract and measuring the carotenoids contained in the gut from carrot ingested after the treatment. By HPLC fractionation and tracking the biological activity with the carrot test, we isolated the sulfakinin EQFDDY(SO3H) GHMRFamide (Pea-SK). A synthetic version of the peptide inhibited food intake when injected at doses of 1 microg (50% inhibition) and 10 microg (60% inhibition). The sulfate group was required for food-intake inhibition. These biological and structural features are similar to those of the gastrin-cholecystokinin (gastrin-CCK) family of vertebrate peptides. However, heterologous feeding assays (human CCK-8 tested on B. germanica, and Pea-SK tested on the goldfish Carassius auratus) were negative. In spite of this, alignment and cluster analysis of these and other structurally similar peptide families suggest that sulfakinins and gastrin-CCKs are homologous, and that mechanisms of feeding regulation involving these regulatory peptides may have been conserved during evolution between insects and vertebrates.

Incidence of hypercalcaemia in haemodialysis patients

Secondary hyperparathyroidism is still one of the main problems affecting the dialysis population. The use of aluminium hydroxide as a phosphate binder is limited by significant long-term toxicity. Therefore, actually, most patients on haemodialysis receive treatment with calcium containing phosphate binders to avoid hyperphosphataemia.

Quantification of ecdysteroids by immunoassay: comparison of enzyme immunoassay and radioimmunoassay

The performance of enzyme immunoassay (EIA) and radioimmunoassay (RIA) in the quantitative analysis of ecdysteroids was compared. The EIA was found to be at least equivalent to the RIA with respect to analytical range and sensitivity and to be more comfortable with respect to safety and time saving. When biological samples were analyzed by both assays a good correlation (r = 0.83) was found. Since the EIA has certain advantages over the RIA, we now recommend the use of the former assay for the quantification of ecdysteroids.