Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial

Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.

Human phenotype caused by biallelic KDM4B frameshift variant

KDM4B (MIM*609765, NM_015015.3, formerly JMJD2B) encodes a histone demethylase and regulates gene expression via demethylation, mainly of H3K9 tri-methylation. Heterozygous KDM4B loss-of-function variants cause autosomal dominant intellectual developmental disorder 65 (MIM#619320), which is characterized by global developmental delay, intellectual disability, language and gross motor delays, structural brain anomalies, characteristic facial features, and clinodactyly. Although the majority of reported patients have de novo pathogenic variants, some patients inherit pathogenic variants from affected parents. To our knowledge, only 23 patients with heterozygous KDM4B variants have been reported to date, and there are no reports of patients with biallelic KDM4B pathogenic variants. Herein, we report a female patient with a biallelic KDM4B frameshift variant (NM_015015.3: c.1384_1394delinsGGG, p.(Leu462Glyfs*43)) located at exon 12 of 23 protein-coding exons, which is thought to be subject to nonsense-mediated mRNA decay and no protein production. She presented developmental and language delays and a hypotonic and characteristic face. The patient's phenotype was more obvious than that of her mother, who is heterozygous for the same variant. Although declining birth rate (embryonic lethality in male mice) in homozygous knockout mice has been demonstrated, our report suggests that homozygous KDM4B frameshift variants can be viable in humans at least female.

Characterization of patients with acutely decompensated cirrhosis who received care in different highly complex emergency services of Medellín, Colombia

INTRODUCTION

Cirrhosis is one of the ten leading causes of death in the Western hemisphere and entails a significant cost of health care.

OBJECTIVE

To describe the sociodemographic, clinical, and laboratory characteristics of patients older than 18 years who received care for acute decompensation of cirrhosis in the emergency services of three highly complex centers in Medellín, Colombia.

MATERIALS AND METHODS

This was an observational retrospective cohort study from clinical records. The results were analyzed by frequency measures and represented in tables and graphics.

RESULTS

In total, 576 clinical records met the inclusion criteria; 287 were included for analysis, and 58.9% were men, with an average age of 64 (± 13.5) years. The most frequent causes of cirrhosis were alcohol intake (47.7%), cryptogenic or unspecified etiology (29.6%), and non-alcoholic fatty liver disease (9.1%). The main reasons for visiting the emergency department were the presence of edema and/or ascites (34.1%), suspicion of gastrointestinal bleeding (26.5%), abdominal pain (14.3%) and altered mental status (13.9%). The most frequent clinical manifestations of an acute decompensation of cirrhosis were ascites (45.6%), variceal hemorrhage (25.4%), hepatic encephalopathy (23.0%), and spontaneous bacterial peritonitis (5.2%). During their treatment, 56.1% of the patients received intravenous antibiotics; 24.0%, human albumin; 24.0%, vasoactive support, and 27.5%, blood products; 21.3% required management in an intensive or intermediate care unit, registering 53 deceased patients for a mortality of 18.5%.

CONCLUSION

Patients who consult the emergency services due to acute decompensation of cirrhosis demand a high amount of health resources, frequently present associated complications, and a high percentage requires management in critical care units and shows a high in-hospital mortality rate.

Diagnostic tool for surveillance, detection and monitoring of the high-risk clone K. pneumoniae ST15

BACKGROUND

The global spread of Klebsiella pneumoniae ST15, causing multi-continental outbreaks, contributes to the movement of resistance genes between clones increasing the antimicrobial resistance crisis. The genomic traits providing it with the ability to outcompete other bacteria and cause epidemics remain unclear.

AIM

To identify the specific genomic traits of K. pneumoniae ST15 to develop a diagnostic test.

METHODS

An outbreak caused by K. pneumoniae occurred in Hospital A Coruña, Spain. Antimicrobial susceptibility analysis and molecular typing (PGFE and MLST) were performed. One isolate of each sequence type was selected for whole-genome sequencing analysis. Comparative analysis of genomes was performed using RAST. BLASTn was used to evaluate the presence of the fhaC and kpiD genes. Two hundred and ninety-four K. pneumoniae from a Spanish nationwide collection were analysed by PCR.

FINDINGS

Genotyping showed that 87.5% of the isolates tested belonged to a clone with a unique PFGE pattern which corresponded to ST15. Comparative genomic analysis of the different STs enabled us to determine the specific genomic traits of K. pneumoniae ST15. Two adherence-related systems (Kpi and KpFhaB/FhaC) were specific markers of this clone. Multiplex-PCR analysis with kpiD and fhaC oligonucleotides revealed that K. pneumoniae ST15 is specifically detected with a sensitivity of 100% and a specificity of 97.76%. The PCR results showed 100% concordance with the MLST and whole-genome sequencing data.

CONCLUSION

K. pneumoniae ST15 possesses specific genomic traits that could favour its dissemination. They could be used as targets to detect K. pneumoniae ST15 with high sensitivity and specificity.

Research priorities in perioperative fluid therapy and hemodynamic monitoring: A Delphi Consensus Survey from the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section (SHTF) of the Spanish Society of Anesthesiology and Critical Care (SEDAR)

BACKGROUND

Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance.

METHODS

Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care.

RESULTS

77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus.

CONCLUSIONS

The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.

On the use of plastic precursors for preparation of activated carbons and their evaluation in CO2 capture for biogas upgrading: a review

In circular economy, useful plastic materials are kept in circulation as opposed to being landfilled, incinerated, or leaked into the natural environment. Pyrolysis is a chemical recycling technique useful for unrecyclable plastic wastes that produce gas, liquid (oil), and solid (char) products. Although the pyrolysis technique has been extensively studied and there are several installations applying it on the industrial scale, no commercial applications for the solid product have been found yet. In this scenario, the use of plastic-based char for the biogas upgrading may be a sustainable way to transform the solid product of pyrolysis into a particularly beneficial material. This paper reviews the preparation and main parameters of the processes affecting the final textural properties of the plastic-based activated carbons. Moreover, the application of those materials for the CO₂ capture in the processes of biogas upgrading is largely discussed.

[Translated article] Primary Cutaneous Lymphoma Registry of the Spanish Academy of Dermatology and Venereology (AEDV): Data for the First 5 Years

BACKGROUND AND OBJECTIVE

Primary cutaneous lymphomas (PCL) are uncommon. Observations based on the first year of data from the Spanish Registry of Primary Cutaneous Lymphomas (RELCP, in its Spanish abbreviation) of the Spanish Academy of Dermatology and Venereology (AEDV) were published in February 2018. This report covers RELCP data for the first 5 years.

PATIENTS AND METHODS

RELCP data were collected prospectively and included diagnosis, treatments, tests, and the current status of patients. We compiled descriptive statistics of the data registered during the first 5 years.

RESULTS

Information on 2020 patients treated at 33 Spanish hospitals had been included in the RELCP by December 2021. Fifty-nine percent of the patients were men; the mean age was 62.2 years. The lymphomas were grouped into 4 large diagnostic categories: mycosis fungoides/Sézary syndrome, 1112 patients (55%); primary B-cell cutaneous lymphoma, 547 patients (27.1%); primary CD30⁺ lymphoproliferative disorders, 222 patients (11%), and other T-cell lymphomas, 116 patients (5.8%). Nearly 75% of the tumors were registered in stage I. After treatment, 43.5% achieved complete remission and 27% were stable at the time of writing. Treatments prescribed were topical corticosteroids (1369 [67.8%]), phototherapy (890 patients [44.1%]), surgery (412 patients [20.4%]), and radiotherapy (384 patients [19%]).

CONCLUSION

The characteristics of cutaneous lymphomas in Spain are similar to those reported for other series. The large size of the RELCP registry at 5 years has allowed us to give more precise descriptive statistics than in the first year. This registry facilitates the clinical research of the AEDV's lymphoma interest group, which has already published articles based on the RELCP data.

Emerging targets for cancer treatment: S100A9/RAGE

Developing better treatments that work for the majority of patients with brain metastasis (BM) is highly necessary. Complementarily, avoiding those therapeutic procedures that will not benefit a specific patient is also very relevant. In general, existing therapies for patients with BM could be improved in terms of molecular stratification and therapeutic efficacy. By questioning the benefit of whole brain radiotherapy as provided nowadays and the lack of biomarkers detecting radioresistance, we identified S100A9 and receptor for advanced glycation end-products (RAGE) as a liquid biopsy biomarker and a potential target for a radiosensitizer, respectively. Both of them are being clinically tested as part of the first comprehensive molecular strategy to personalized radiotherapy in BM.

Primary Cutaneous Lymphoma Registry of the Spanish Academy of Dermatology and Venereology (AEDV): Data for the First 5 Years

BACKGROUND AND OBJECTIVE

Primary cutaneous lymphomas (PCL) are uncommon. Observations based on the first year of data from the Spanish Registry of Primary Cutaneous Lymphomas (RELCP, in its Spanish abbreviation) of the Spanish Academy of Dermatology and Venereology (AEDV) were published in February 2018. This report covers RELCP data for the first 5 years.

PATIENTS AND METHODS

RELCP data were collected prospectively and included diagnosis, treatments, tests, and the current status of patients. We compiled descriptive statistics of the data registered during the first 5 years.

RESULTS

Information on 2020 patients treated at 33 Spanish hospitals had been included in the RELCP by December 2021. Fifty-nine percent of the patients were men; the mean age was 62.2 years. The lymphomas were grouped into 4 large diagnostic categories: mycosis fungoides/Sézary syndrome, 1112 patients (55%); primary B-cell cutaneous lymphoma, 547 patients (27.1%); primary CD30+lymphoproliferative disorders, 222 patients (11%), and other T-cell lymphomas, 116 patients (5.8%). Nearly 75% of the tumors were registered in stage I. After treatment, 43.5% achieved complete remission and 27% were stable at the time of writing. Treatments prescribed were topical corticosteroids (1369 [67.8%]), phototherapy (890 patients [44.1%]), surgery (412 patients [20.4%]), and radiotherapy (384 patients [19%]).

CONCLUSION

The characteristics of cutaneous lymphomas in Spain are similar to those reported for other series. The large size of the RELCP registry at 5 years has allowed us to give more precise descriptive statistics than in the first year. This registry facilitates the clinical research of the AEDV's lymphoma interest group, which has already published articles based on the RELCP data.

[Superficial siderosis of the central nervous system. Report of one case]

Superficial siderosis of the central nervous system is produced by the deposit of hemosiderin within the subpial layers of the central nervous system and central parts of the cranial nerves, leading to progressive degeneration. We report a 55-year-old male who consulted for hearing loss and long-standing progressive decrease in visual acuity, associated with sudden onset of left hemiparesis. A brain CAT scan showed subacute ischemic lesions in the territory of the right posterior cerebral artery (thalamus and right subcortical temporal regions), old ischemic lesions in the right subcortical occipital regions and cerebellar atrophy. A magnetic resonance confirmed the lesions and the presence of superficial diffuse siderosis. A cerebrospinal fluid analysis showed slight xanthochromia, 26 leukocytes/mm3, glucose 51 mg/dL and proteins 1.23 g/L. He was managed with aspirin in low doses and statins. His motor function improved and was discharged two weeks after admission.

Executive summary on the treatment of type 2 diabetes mellitus in elderly or frail individuals. 2022 update of the 2018 consensus document "Treatment of type 2 diabetes mellitus in the elderly"

The population with type 2 DM (DM2) is highly heterogeneous, representing an important challenge for healthcare professionals. The therapeutic choice should be individualized, considering the functional status, frailty, the occurrence of comorbidities, and the preferences of patients and their caregivers. New evidence on the cardiovascular and renal protection of specific therapeutic groups and on the usefulness of new technologies for DM2 management, among other aspects, warrant an update of the consensus document on the DM2 in the elderly that was published in 2018.

Effect of Prognostic Guided Management of Patients With Acute Pulmonary Embolism According to the European Society of Cardiology Risk Stratification Model

Background

A recent trial showed that management driven by prognostic assessment was effective in reducing the length of stay (LOS) for acute stable pulmonary embolism (PE). The efficacy and safety of this strategy in each subgroup of risk stratification remains unknown.

Methods

We conducted a post-hoc analysis of the randomized IPEP study to evaluate the effect of a management strategy guided by early use of a prognostic pathway in the low- and intermediate-high risk subgroups defined by the European Society of Cardiology (ESC) model. These subgroups were retrospectively identified in the control arm. The primary outcome was LOS. The secondary outcomes were 30-day clinical outcomes.

Results

Of 249 patients assigned to the intervention group, 60 (24%) were classified as low-, and 30 (12%) as intermediate-high risk. Among 249 patients assigned to the control group, 66 (27%) were low-, and 13 (5%) intermediate-high risk. In the low-risk group, the mean LOS was 2.1 (±0.9) days in the intervention group and 5.3 (±2.9) days in the control group (P < 0.001). In this group, no significant differences were observed in 30-day readmissions (0% vs. 3.0%, respectively), all-cause (0% vs. 0%) and PE-related mortality rates (0% vs. 0%), or severe adverse events (0% vs. 1.5%). In the intermediate-high risk group, the mean LOS was 5.3 (±1.8) days in the intervention group and 6.5 (±2.5) days in the control group (P = 0.08). In this group, no significant differences were observed in 30-day readmissions (3.3% vs. 3.0%, respectively), all-cause (6.7% vs. 7.7%) and PE-related mortality rates (6.7% vs. 7.7%), or severe adverse events (16.7% vs. 15.4%).

Conclusion

The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE without comprising safety across subgroups of risk stratification.

Clinical Trial Registration

[ClinicalTrials.gov], Identifier [NCT02733198].

Effect of decreasing dietary crude protein in fattening calves on the emission of ammonia and greenhouse gases from manure stored under aerobic and anaerobic conditions

Dietary strategies can potentially help to reduce nitrogen (N) emissions and decrease the environmental impact of beef production. This study aimed to evaluate the effects of dietary crude protein (CP) concentration on animal performance, N excretion, and manure N volatilisation of finishing Holstein animals. In a first study, 105 Holstein bulls (BW 344 ± 2.6 kg; age 252 ± 0.9 days) were allocated to eight pens to evaluate the effect of two treatments (medium (M) and low (L), which contained CP 14.5% and 12% on a DM basis, respectively) on performance, and results confirmed that dietary CP decrease did not impair animal growth. In a second study, N excretion study, 24 Holstein heifers (BW 310 ± 5.3 kg; age 251 ± 1.4 days) were distributed randomly depending on the initial BW to three treatments (high (H), M, and L, which contained CP 17%, 14.5% and 12% on a DM basis, respectively). Based on N excretion, urinary N excretion was greater (P < 0.001) in H than in M and L diets, but no differences in faecal N excretion were observed among treatments. A third study with in vitro assays under aerobic and anaerobic conditions was designed to analyse gaseous emissions (volatilisation of N and carbon, C) during the storage stage of manure. Manure, faecal and urine samples, mixed at a ratio of 1:1 (wet weight), were collected during the N excretion study (manure-H, manure-M, manure-L). Under aerobic conditions, manure-M and manure-L showed a delay of 4-5 days in manure ammonia emission compared with manure-H (P < 0.01). Total N content was lower (P < 0.01) in manure-L compared with manure-M and manure-H, but N volatilisation (percentage relative to initial N) in manure-L and manure-M was greater (P < 0.01) than in manure-H. In contrast, the anaerobic N volatilisation was 20 times greater in manure-M and 10 times greater in manure-H compared with manure-L. Under aerobic and anaerobic conditions, the emission of C, as C-CO₂ and C-CH₄, was greater in manure-L than in manure-H and manure-M. Therefore, the decrease of dietary CP concentration from 17% to 14.5% and 12% is an efficient strategy to reduce urinary N excretion by 40%, without impairing performance, and also to reduce manure N losses through ammonia volatilisation under anaerobic conditions. However, a dietary CP content of 14.5% resulted in less environmental impact than a CP content of 12.8% when also considering manure emissions under aerobic or anaerobic conditions.

Blood caspase-8 concentrations and mortality among septic patients

OBJECTIVE

No data are available on blood caspase-8 concentrations (the initiator caspase in the extrinsic apoptosis pathway) in septic patients. The present study thus describes the blood caspase-8 concentrations in survivors and non-survivors, and examines the possible association between blood caspase-8 concentrations and mortality in septic patients.

DESIGN

A prospective observational study was carried out.

SETTING

Three Spanish Intensive Care Units.

PATIENTS

Septic patients.

INTERVENTIONS

Serum caspase-8 concentrations were determined at the diagnosis of sepsis.

MAIN VARIABLE OF INTEREST

Mortality after 30 days.

RESULTS

Patients not surviving at day 30 (n=81) compared to surviving patients (n=140) showed higher serum caspase-8 levels (p<0.001). Multiple logistic regression analysis found an association between serum caspase-8 levels>43.5ng/ml and mortality (OR=3.306; 95%CI=1.619-6.753; p=0.001). The area under the curve (AUC) for mortality predicted by serum caspase-8 levels was 67% (95% CI=60-73%; p<0.001).

CONCLUSIONS

The novel findings of our study were that blood caspase-8 concentrations are higher in non-survivors than in survivors, and that there is an association between blood caspase-8 concentrations and mortality in septic patients.

Characterization of the hypertriglyceridemic waist phenotype in patients with type 2 diabetes mellitus in Spain: an epidemiological study

BACKGROUND AND OBJECTIVES

In patients with type 2 diabetes mellitus (DM2), the presence of increased waist circumference and triglycerides is a reflection of increased visceral fat and insulin resistance. However, information about the prevalence and clinical characteristics of the hypertriglyceridemic waist (HTGW) phenotype in patients with DM2 is scarce. The aim of the present study was to analyze the prevalence and characteristics of DM2 patients with HTGW.

METHODS

We analyzed 4214 patients with DM2 in this epidemiological, cross-sectional study conducted in primary care centers across Spain between 2011 and 2012. The HTGW phenotype was defined as increased waist circumference according to the International Diabetes Federation criteria for Europids (≥ 94 cm for men and ≥ 80 cm for women) with the presence of triglyceride levels ≥ 150 mg/dL. We compared the demographic, clinical and analytical variables according to the presence or absence of the HTGW phenotype.

RESULTS

Thirty-five percent of patients presented the HTGW phenotype. Patients with the HTGW phenotype had a higher body mass index (31.14 ± 4.88 vs. 29.2 ± 4.82 kg/m2; p < .001) and glycated hemoglobin levels (7.38 ± 1.2% vs. 7 ± 1.07%; p < .001). The presence of hypertension, peripheral arterial disease, cardiac insufficiency and microvascular complications were higher when compared with patients without the HTGW phenotype. Patients with the HTGW phenotype were less adherent to prescribed diet (69.8 vs. 81%; p < .001), exercise (44.6 vs. 58.2%; p < .001) and presented greater weight increase within the year prior to the study visit (29.4 vs. 22.5%; p < .001).

CONCLUSIONS

The HTGW phenotype is prevalent in the Spanish DM2 population and identifies a subgroup of patients with higher cardiometabolic risk and prevalence of diabetic complications.

Simple template-based optimization for pediatric total lymphoid irradiation (TLI) radiotherapy treatments

Total lymphoid irradiation (TLI) is used in the management of pediatric allogeneic hematopoietic stem cell transplantation (HSCT. This work aims to simplify the treatment planning process for TLI via a proposed template using the volumetric modulated arc therapy (VMAT) technique. Fifteen pediatric patients were planned, prescribed to 8 Gy in 4 fractions. Cost functions included in the template were the ones for the planning target volume (PTV), and conformality cost function (CCF) for the rest of the patient's volume. Conformity index (CI), homogeneity index (HI), conformation number (CN), gradient index (GI), integral dose, and doses to the organs at risk achieved with the template were reported. Cost function influence over various indexes was studied by Wilcoxon signed ranks test. Same 15 patients were planned with 3-dimensional conventional radiotherapy (3D-CRT) technique for comparison. Mean CI and HI were 1.33 and 0.13, respectively, which indicates good dose conformation and homogeneity. Mean CN and GI values were 0.69 and 4.51, respectively. Mean PTV coverage was reached (V_100% > 95%). No correlation between the CCF and indexes values was found (p > 0.05). Doses to organs at risk (OARs) were as low as possible without losing PTV coverage. VMAT plan showed higher levels of conformation and similar homogeneity as 3D-CRT plans. Doses to OARs were inferior with VMAT except for the right kidney. The proposed template simplifies the planning of TLI treatments, and it is able to create acceptable plans with little modification in order to reduce doses to certain organs like the kidneys or the heart. VMAT technique showed higher conformation and lower doses to OAR compared to 3D-CRT.

P02.01 A strategy to personalize the use of radiation in patients with brain metastasis based on S100A9-mediated resistance

BACKGROUND

Finding effective treatment options for patients with brain metastasis remains an unmet need. Given the limitations imposed by the blood-brain-barrier for systemic approaches, radiotherapy offers a superior ability to access the brain. While clinical practice recently adapted the use of stereotactic radiosurgery (SRS), Whole-Brain-Radiotherapy (WBRT) continuous to be an important treatment option, since many patients present with multifocal lesions or bad performance scores, rendering them ineligible for SRS. Unfortunately, overall survival of patients remains unaffected by radiotherapy. Despite this clinical data, the molecular mechanisms that allow metastatic cells to resist radiotherapy in the brain is unknown.

MATERIAL AND METHODS

We have applied WBRT to experimental brain metastasis from lung and breast adenocarcinoma and validated their resistance in vivo.

RESULTS

An unbiased search to identify potential mediators of resistance identified the S100A9-RAGE-NFκB-JunB pathway. Targeting this pathway genetically reverts the resistance to radiotherapy and increases therapeutic benefits in vivo. In two independent cohorts of brain metastasis from lung and breast adenocarcinoma patients, levels of S100A9 correlate with the response to radiotherapy, offering a novel approach to stratify patients according to their expected benefit. In order to make this biomarker also available for brain metastasis patients receiving palliative WBRT without preceding surgery, we complemented our tumor-specimen based approach with the less invasive detection of S100A9 from liquid biopsies. Here, serum S100A9 also correlated with a worse response to WBRT in brain metastasis patients. Furthermore, we have validated the use of a blood-brain-barrier permeable RAGE inhibitor to restore radio-sensitivity in experimental brain metastasis models in vivo and in patient-derived organotypic cultures of radio-resistant brain metastasis ex vivo.

CONCLUSION

We identified S100A9 as a major mediator of radio-resistance in brain metastasis and offer the molecular framework to personalize radiotherapy by exploiting it as a biomarker and as a therapeutic target, thus maximizing the benefits for the patient.

External cranial expansion as treatment of intracranial hypertension. Technical note

Intracranial hypertension may be idiopathic or due to multiple etiologies. Some bone dysplasias and chronic shunt overdrainage syndrome may sometimes lead to intracranial hypertension associated with craniocerebral disproportion due to thickening of cranial diploe. The internal cranial expansion procedure has been used for patients with intracranial hypertension, whether or not associated with craniocerebral disproportion. Its purpose is to increase the intracranial volume by drilling down the inner table. This technique enables the craniocerebral disproportion to be improved and intracranial hypertension reduced. In other etiologies of intracranial hypertension with non-thickened diploe, internal cranial expansion may not be enough to resolve the hypertension. For these cases we propose a modification of the technique by expanding the cranial vault outwards; external cranial expansion. We describe this technique as used in a pediatric patient who presented with chronic headache, tonsillar ectopia, and sleep apnea syndrome. This patient also had a multisuture craniosynostosis, a non-thickened diploe, and intracranial hypertension.

Psychiatric comorbidity in a patient with opsoclonus-myoclonus syndrome. differences in the transition from childhood to adulthood: A case report

Introduction

Opsoclonus-Myoclonus syndrome (OMS), also known as Kinsbourne syndrome, is a paraneoplasic pediatric condition characterized by erratic eye movements and generalized myoclonus. Previous studies have described a wide range of psychiatric comorbidities in children with this syndrome. Cognitive impairment (especially intellectual capacity and language), affective symptoms (irritability, poor mood regulation) and behavioral problems are the most frequent presentations (1). However, there is a lack of literature describing the progression of this symptoms when the patient reaches the adulthood.

Objectives

To illustrate the psychiatric comorbidity of an adult patient with Opsoclonus-Myoclonus syndrome.

Methods

We present one case-report and literature research of the topic.

Results

We present a 18 year old girl diagnosed with OMS and Graves-Basedow hyperthyroidism. During her childhood she started presenting attention and comprehension difficulties. She was diagnosed with an Attention Deficit Hyperactivity Disorder (ADHD) and started treatment with methylphenidate. She completed elementary and secondary education. During the adulthood, the main psychiatric comorbidity was related to affective symptoms. We observed an impaired mood regulation, hypothymia, anhedonia, and frequent episodes of irritability, which persisted after the thyroid regulation. This caused incremented anxious symptoms and insomnia that were treated with mirtazapine and lormetazepam. After some weeks, she fulfilled criteria of a depressive episode and we started antidepressant treatment with vortioxetine.

Conclusions

- Adult patients diagnosed with OMS during childhood can persist presenting ADHD as a comorbidity. - Affective symptoms, and even a major depressive episode, should be considered during the follow-up of this population. Insight of the cognitive limitations could be a risk factor for a depression.

Disclosure

No significant relationships.

Association Between Hyponatremia and Maintenance Intravenous Solutions in Critically Ill Children: A Retrospective Observational Study

Objetive: We sought to determine the association between maintenance intravenous solutions and the presence of hyponatremia in children in pediatric intensive care (PICU). Materials and Methods: An analytical observational study in children hospitalized in the PICU between January 2015 and December 2018. Patients who received maintenance fluids within the first 48 h after admission and who had at least two serum sodium levels drawn during this time were included. Measurements and Main Results: A total of 1,668 patients were admitted to the PICU during the study period, 503 of whom met the inclusion criteria. The median age was 24 months (IQR 8-96) and 50.9% were female. Altogether, 24.1% of the children developed hyponatremia; it was more frequent in those who received hypotonic solutions (63 vs. 37%; OR 1.41 95% CI 0.92, 2.15 p = 0.106), who also had a longer hospital stay (20 vs. 14 days, difference in means 8 days, 95% CI 2.67, 13.3, p = 0.001). Children who received loop diuretics and those who were post-operative had a greater risk of developing hyponatremia if they received hypotonic solutions (aOR 2.1 95% CI 1.41, 3.0, p = 0.000). Those with balanced isotonic solutions had a lower risk of developing hyponatremia (aOR 0.59 95% CI 0.35, 0.99, p = 0.004) and hyperchloremia (aOR 0.51 95% CI 0.34, 0.77, p = 0.000), adjusted for disease severity. A greater risk of death was found in the group with severe hyponatremia <130 mEq/L (aOR 9.75 95% CI 1.64-58.15; p = 0.01). Conclusions: Hyponatremia associated with the use of hypotonic maintenance solutions occurs in one out of four children in intensive care. The use of these solutions is associated with a longer hospital stay, and the main risk groups are post-operative patients and those who receive loop diuretics. Clinical studies are needed to determine which maintenance solutions have the greatest efficacy and safety in critically ill children.

Implications of Abnormal Troponin Levels With Normal Right Ventricular Function in Normotensive Patients With Acute Pulmonary Embolism

Among patients with pulmonary embolism (PE), various permutations of normal or abnormal cardiac troponin results and normal or abnormal echocardiographic right ventricular function are encountered in clinical practice. We aimed to explore whether there is a true gradient of risk based on troponin and echocardiographic results. This study included normotensive patients with PE from the PROgnosTic valuE of CT scan in hemodynamically stable patients with acute symptomatic pulmonary embolism (PROTECT) study. Patients were categorized as having -Troponin/-Echo, -Troponin/+Echo, +Troponin/-Echo, and +Troponin/+Echo. The primary outcome was 30-day “complicated course,” including death from any cause, hemodynamic collapse, or recurrent PE. Secondary outcomes included individual adverse event rates. Of the 834 patients who had echocardiographic and troponin results, 569 patients (68%) had -Troponin/-Echo, 126 patients (15%) had -Troponin/+Echo, 74 patients (8.9%) had +Troponin/-Echo, and 65 patients (7.8%) had +Troponin/+Echo. The incidence of 30-day complicated course was 4.6% in patients with -Troponin/-Echo, 11.9% in patients with -Troponin/+Echo, 13.5% in patients with +Troponin/-Echo, and 16.9% in patients with +Troponin/+Echo (P for trend <0.001). In the subgroup of patients with a high-risk sPESI (i.e., intermediate-risk according to the ESC guidelines) (n = 527), the incidence of 30-day complicated course was 14.9% in patients with -Troponin/+Echo, 18.5% in patients with +Troponin/-Echo, and 17.5% in patients with +Troponin/+Echo (P for trend <0.01). In patiens with PE, there seems to be a risk gradient based on troponin and echocardiographic results. This study did not detect a significant risk difference in those with +Troponin/-Echo compared with -Troponin/+Echo.

Liquid Hot Water Pretreatment and Enzymatic Hydrolysis as a Valorization Route of Italian Green Pepper Waste to Delivery Free Sugars

In this work, liquid hot water pretreatment (autohydrolysis) was used to improve enzymatic hydrolysis of a commonly consumed vegetable waste in Spain, Italian green pepper, to finally produce fermentable sugars. Firstly, the effect of temperature and contact time on sugar recovery during pretreatment (in insoluble solid and liquid fraction) was studied in detail. Then, enzymatic hydrolysis using commercial cellulase was performed with the insoluble solid resulting from pretreatment. The objective was to compare results with and without pretreatment. The results showed that the pretreatment step was effective to facilitate the sugars release in enzymatic hydrolysis, increasing the global sugar yield. This was especially notable when pretreatment was carried out at 180 °C for 40 min for glucose yields. In these conditions a global glucose yield of 61.02% was obtained. In addition, very low concentrations of phenolic compounds (ranging from 69.12 to 82.24 mg/L) were found in the liquid fraction from enzymatic hydrolysis, decreasing the possibility of fermentation inhibition produced by these components. Results showed that Italian green pepper is an interesting feedstock to obtain free sugars and prevent the enormous quantity of this food waste discarded annually.

Blood caspase-8 concentrations and mortality among septic patients

OBJECTIVE

No data are available on blood caspase-8 concentrations (the initiator caspase in the extrinsic apoptosis pathway) in septic patients. The present study thus describes the blood caspase-8 concentrations in survivors and non-survivors, and examines the possible association between blood caspase-8 concentrations and mortality in septic patients.

DESIGN

A prospective observational study was carried out.

SETTING

Three Spanish Intensive Care Units.

PATIENTS

Septic patients.

INTERVENTIONS

Serum caspase-8 concentrations were determined at the diagnosis of sepsis.

MAIN VARIABLE OF INTEREST

Mortality after 30 days.

RESULTS

Patients not surviving at day 30 (n=81) compared to surviving patients (n=140) showed higher serum caspase-8 levels (p<0.001). Multiple logistic regression analysis found an association between serum caspase-8 levels>43.5ng/ml and mortality (OR=3.306; 95%CI=1.619-6.753; p=0.001). The area under the curve (AUC) for mortality predicted by serum caspase-8 levels was 67% (95% CI=60-73%; p<0.001).

CONCLUSIONS

The novel findings of our study were that blood caspase-8 concentrations are higher in non-survivors than in survivors, and that there is an association between blood caspase-8 concentrations and mortality in septic patients.

Characterization of the hypertriglyceridemic waist phenotype in patients with type2 diabetes mellitus in Spain: An epidemiological study

BACKGROUND AND OBJECTIVES

In patients with type2 diabetes mellitus (DM2), the presence of increased waist circumference and triglycerides is a reflection of increased visceral fat and insulin resistance. However, information about the prevalence and clinical characteristics of the hypertriglyceridemic waist (HTGW) phenotype in patients with DM2 is scarce. The aim of the present study was to analyze the prevalence and characteristics of DM2 patients with HTGW.

METHODS

We analyzed 4214 patients with DM2 in this epidemiological, cross-sectional study conducted in primary care centers across Spain between 2011 and 2012. The HTGW phenotype was defined as increased waist circumference according to the International Diabetes Federation criteria for Europids (≥94cm for men and ≥80cm for women) with the presence of triglyceride levels ≥150mg/dl. We compared demographic, clinical and analytical variables according to the presence or absence of the HTGW phenotype.

RESULTS

Thirty-five percent of patients presented the HTGW phenotype. Patients with the HTGW phenotype had a higher body mass index (31.14±4.88 vs. 29.2±4.82kg/m2; P<.001) and glycated hemoglobin levels (7.38±1.2% vs. 7±1.07%; P<.001). The presence of hypertension, peripheral arterial disease, cardiac insufficiency and microvascular complications were higher when compared with patients without the HTGW phenotype. Patients with the HTGW phenotype were less adherent to prescribed diet (69.8 vs. 81%; P<.001), exercise (44.6 vs. 58.2%; P<.001) and presented greater weight increase within the year prior to the study visit (29.4 vs. 22.5%; P<.001).

CONCLUSIONS

The HTGW phenotype is prevalent in the Spanish DM2 population and identifies a subgroup of patients with higher cardiometabolic risk and prevalence of diabetic complications.

Multimodal semantic revision during inferential processing: The role of inhibitory control in text and picture comprehension

Although language comprehension usually requires multimodal information, no study to date has investigated how comprehenders deal with the revision of a text's interpretation when different modalities are involved. Twenty-four young adults listened to a story prompting an inference (e.g., polar bear), and then saw a picture that was either consistent (polar bear) or inconsistent but still plausible (penguin). Larger negativity (N400) in the inconsistent picture indicated successful inferential monitoring. Subsequently, a sentence carried the disambiguating word which was either expected ("bear") or unexpected ("penguin") in relation to the auditory-verbal information. Larger negativity in the unexpected word coming from the consistent picture suggested that comprehenders had difficulties selecting the unexpected concept when previous information was contradictory. More importantly, this effect was modulated by inhibitory control, where a higher resistance to distractor interference (flanker task) was associated with a better ability to suppress pictorial information, therefore preventing semantic competition. Similarly, accuracy measured in a final comprehension question demonstrated that higher inhibitory control was related to a more efficient ability to revise the situation model across modalities. Our findings speak to a relationship between story comprehension and mental flexibility during multimodal processing.

TLI in pediatric patients

PURPOSE

Hematopoietic progenitor cell transplantation (HSCT) is a procedure used in different hematological diseases as part of the curative treatment, so the investigators propose a system of conditioning of reduced intensity based on total lymphoid irradiation (TLI) as an alternative to the classic total body irradiation (TBI) followed by haploidentical transplantation in patients compatible with a single HLA haplotype, as an alternative to patients who do not have an HLA compatible donor.

MATERIALS AND METHODS

A cohort of 25 patients with hematological disease underwent haploidentical HSCT from February 2015 to May 2018, conditioned with TLI from day - 10 (2-4 days of treatment) followed by thiotepa (5 mg/kg/12 h) and melphalan (70 mg/m²/day) prior to HSCT and prophylaxis with ciclosporin (1.5 mg/kg/12 h). 2 Gy/fraction was administered to complete 8 Gy with IMRT and VMAT technique.

RESULTS

12% rejection of the transplant was obtained with acute GVHD < II (48%) and chronic GVHD 12%. No acute toxicity was recorded in irradiated patients and 56% survival of patients at the end of follow-up.

CONCLUSION

Conditioning the haploidentical transplant with TLI, IMRT, and VMAT techniques compared with TBI and RT3D-C techniques is a feasible technique that helps inducing the necessary immunosuppression in patients with a high risk of graft rejection, minimal adverse effects, low incidence of GVHD, and high survival rate.

Do all CSR news affect market value equally?

Purpose

The purpose of this study explores the effects that media coverage of corporate social responsibility (CSR) news related to primary stakeholders (e.g. customers, employees and investors) and secondary stakeholders (e.g. community) have on the market value of companies, measured as the impact generated in the positive and negative abnormal returns for those companies.

Design/methodology/approach

Using a sample of 195 online papers published in the most important Spanish business newspaper during 2015, the authors implement an event study and a regression analysis that confirm the importance of CSR news for corporate financial goals.

Findings

The findings show that negative CSR news related to primary stakeholders such as investors and customers generate significant abnormal returns for companies that are notably larger than the abnormal returns generated by secondary stakeholders (e.g. community). Similarly, positive news related to primary stakeholders such as employees are the only positive news that affect market reactions significantly.

Originality/value

The study provides an empirical analysis that clarifies how media coverage of different types of CSR news affect the market value of companies. In doing so, the paper contributes to previous literature significantly because scant research exists that has compared the differential effects of CSR news focused on primary and secondary stakeholders. The findings are discussed under the premises of the managerial perspective of stakeholder theory.

Development and validation of a multi-dimensional customer-based scale to measure perceptions of corporate social responsibility (CSR)

Purpose

Based on a review of previous literature that revealed a gap in the measurement of corporate social responsibility (CSR) from a customer perspective. The purpose of this study is to propose a multi-dimensional scale to measure customer perceptions of CSR.

Design/methodology/approach

Using a systematic development process, the scale items were generated through the review of CSR literature and the opinion of academic experts. The scale was validated using data collected from 393 customers of telecom industry. Data were initially subjected to exploratory factor analysis to identify the underlying scale dimensions. Confirmatory factor analysis was also conducted to validate the scale, test for reliability, convergent and discriminant validity.

Findings

The resulting scale is compounded of 30 items that load on five dimensions: developmental, ethical, relationship-building, responsiveness and information-sharing responsibilities.

Practical implications

The proposal of reliable measurement tools for evaluating customer perceptions is especially relevant for companies because of their significant role in influencing the design and implementation of corporate actions. The multi-dimensional scale developed in this study helps scholars and practitioners to better understand customer perceptions of the CSR actions that companies implement to improve these stakeholders’ satisfaction. In doing so, the scale is especially useful for companies to measure how well they respond to customer needs in their daily routines.

Originality/value

There is a significant lack of research into the development of reliable and valid tools to measure CSR from a customer perspective. The contribution of this study focuses on the identification of the five dimensions that determine CSR toward customers while it also provides a detailed scale to measure customer perceptions of these CSR dimensions.

Goal-directed fluid therapy on laparoscopic colorectal surgery within enhanced recovery after surgery program

INTRODUCTION

Enhanced recovery after surgery protocols (ERAS) are used in peri-operative care to reduce the stress response to surgical aggression. As fluid overload has been associated with increased morbidity and delayed hospital discharge, a major aspect of this is fluid management. Intra-operative goal-directed fluid protocols have been shown to reduce post-operative complications, particularly in high risk patients.?.

OBJECTIVE

To compare 2fluid therapy models (zero-balance versus goal-directed fluid therapy) in patients who were scheduled for laparoscopic colorectal surgery within an ERAS program, recording the rate of complications such as surgical site infection, ileus, post-operative náusea and vomiting, and variability of the estimated glomerular filtration rate (eGFR).

MATERIALS AND METHODS

An observational, retrospective study was conducted including adults who were scheduled for elective laparoscopic colorectal surgery within an ERAS program, and to investigate the postoperative complication rate.

RESULTS

A total of 128 patients were included in this study; 43 (33.6%) in the zero-balance group and 85 (66.4%) in the goal-directed fluid therapy group. The total fluids administered was lower in the goal-directed fluid therapy group, as well as the incidence of post-operative complications (surgical site infection, anastomotic leak, ileus, and postoperative náusea and vomiting). No significant differences were found for length of stay, intra-operative urine output, and variability of the eGFR.?.

CONCLUSION

The results of this study show that by using a goal-directed fluid therapy algorithm, the total amount of fluids administered can be reduced, as well as obtaining a lower incidence of post-operative complications.

Cross-Sectional Characterization of Albumin Glycation State in Cerebrospinal Fluid and Plasma from Alzheimer's Disease Patients

We determined albumin post-translational modifications (PTMs) by mass spectrometry (MS) in plasma and cerebrospinal fluid (CSF) from 31 Alzheimer's disease (AD) patients (with 27 samples of paired plasma-CSF from the same patients). Results were cross-sectionally compared with healthy controls. For percentage of relative intensity of glycated isoforms, plasma albumin was globally more glycated in AD patients than in healthy controls (P<0.01). MS results in plasma were confirmed by a quantitative enzymatic assay (Lucica GA-L) for albumin early-glycation detection. In CSF there were no global glycation differences detected by MS, although a different pattern of glycated isoforms was observed. Oxidized+glycated and cysteinylated+glycated isoforms were increased in both plasma and CSF of AD patients in comparison with healthy controls (P<0.001). Furthermore, AD patients showed higher glycation in plasma than in CSF (P<0.01). Our data support the role of glycation and oxidative stress in AD.

Optimization of the sugar hydrothermal extraction process from olive cake using neuro-fuzzy models

The optimization of the hydrothermal extraction step in the biorefinery scheme in order to obtain sugars and antioxidants from olive cake was carried out. This process using water and low temperatures for the olive cake has not been previously studied by other authors. Central Composite Design of experiments was carried out. Four variables and three levels for each variable were tested: temperature (50, 70 and 90 °C) time (60, 120, 180 min), average particle diameter (0.42, 0.96 and 1.5 mm) and solid/liquid ratio (0.15, 0.20, 0.25). The main aim was to understand the relationship between the process variables and the yield of extraction of glucose, xylose, polyphenols and oligomers. The variables which most influenced the process were particle diameter and solid/liquid ratio. The experimental values were adjusted to a classical polynomial model and to a neuro-fuzzy system. The neuro-fuzzy demonstrated to be much more accurate when predicting the experimental values.

Kinetic study of thermal degradation of olive cake based on a scheme of fractionation and its behavior impregnated of metals

This research aims to provide a better knowledge of the thermal decomposition of the olive cake as well as this lignocellulosic material loaded, in a previous stage of biosorption, with heavy metals for its use in processes of energy recovery. Firstly, isolation of constituents of the olive cake was carried out. Then, experiments were performed by thermogravimetric analysis (TGA) and differential thermogravimetry (DTG) under inert and oxidative atmosphere at a heating rate of 15 K/min for each isolated fraction. Next, adequate reactions schemes were proposed to find kinetic parameters. Validation of these schemes were verified by the goodness of fitting between experimental and simulated data. Also, some important combustion characteristics such as ignition and burnout temperatures were determined. With regard to the effect of metals, cadmium, copper, chromium, nickel and lead present in metal-loaded olive cake did not modify values of kinetic parameters which described the thermal decomposition processes.

Indicator performance after the implementation of the Spanish Consensus Document for the control of hyperglycemia in the hospital and at discharge

BACKGROUND AND AIMS

Information for the adequate management of diabetic patients at hospital discharge is limited. We aimed to evaluate the impact of implementation of recommendations of the Spanish consensus for the management hospital discharge in patients with type 2 diabetes or hyperglycaemia during hospitalization.

METHODS

Observational multicentric study with a prospective and a retrospective colection of patients with type 2 diabetes /hyperglycaemia (>140mg/dl) during hospitalization from 19 Spanish hospitals. Quality indicators in discharge report, antidiabetic therapy, HbA_1c and adverse events were gathered at hospital admission, hospital discharge and 3 month post-discharge.

RESULTS

199 and 75 subjects in the prospective and retrospective group respectively were included. The indicators of quality in the hospital discharge reports was higher in the prospective group (P<.001). The proportion of patients with insulin, oral antidiabetic drugs (OADs), and insulin+OADs was modified at discharge in patients with HbA_1c<7.5% (P<.005) and ≥7.5% (P<.001) in the prospective group and in patients with HbA 1c ≥7.5% (P<.001) in the retrospective group. At 3 month post-discharge HbA_1c levels decreased from 8.2±1.9% to 7.3±1.2% (P<.001) in the prospective group, and from 8.3±1.5% to 7.2±1.2% (P<.001) in the retrospective group. Hypoglycaemic and hyperglycaemic episodes and hospital readmissions were similar in both groups.

CONCLUSIONS

Implementation of Spanish consensus recommendations for the management of hospital discharge in patients with diabetes type 2 or hyperglycaemia considerably improved the registration of quality indicators in the discharge report. Reconciliation of antidiabetic medication at the time of hospital discharge, improves glycaemic control after hospital discharge.