The management of paediatric acute pain in Spain in 2021: Results of a national survey among paediatric anaesthesiologists

OBJECTIVE

To improve knowledge about routine clinical practice in the management of paediatric acute pain in Spain.

METHODS

A telematic survey was conducted via the Internet on a representative sample of healthcare professionals involved in the management of paediatric acute pain (specifically anaesthesiologists) in Spain. The survey included 28 questions about their usual clinical practice in the assessment and treatment of acute pain, and also training and organisational aspects in paediatric acute pain.

RESULTS

The survey was completed during March 2021 by 150 specialists in anaesthesiology. The respondents widely experienced in the management of acute paediatric pain (mean years of experience: 14.3: SD: 7.8), essentially in acute postoperative pain (97% of cases). Although 80% routinely used validated paediatric acute pain assessment scales, only 2.6% used specific scales adapted for patients with cognitive impairment. Most of the respondents routinely used analgesic drugs such as paracetamol (99%) or metamizole (92%), but only 84% complemented these drugs with a loco-regional blocking technique or other non-steroidal anti-inflammatory drugs (62%). Furthermore, only 62.7% acknowledged having received specific training in paediatric acute pain, only 45% followed hospital institutional protocols, and a scant 28% did so through paediatric pain units.

CONCLUSIONS

The survey identified important points for improvement in the training and organisation of acute pain management in Spanish paediatric patients.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

A critical review of the perioperative fluid therapy and hemodynamic monitoring recommendations of the Enhanced Recovery of the Adult Pathway (RICA): A position statement of 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)

In an effort to standardize perioperative management and improve postoperative outcomes of adult patients undergoing surgery, the Ministry of Health, through the Spanish Multimodal Rehabilitation Group (GERM), and the Aragonese Institute of Health Sciences, in collaboration with multiple Spanish scientific societies and based on the available evidence, published in 2021 the Spanish Intensified Adult Recovery (RICA) guideline. This document includes 12 perioperative measures related to fluid therapy and hemodynamic monitoring. Fluid administration and hemodynamic monitoring are not straightforward but are directly related to postoperative patient outcomes. 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) has reviewed these recommendations and concluded that they should be revised as they do not follow an adequate methodology.

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.

Optical properties of ZnFe2O4 nanoparticles and Fe-decorated inversion domain boundaries in ZnO

The maximum efficiency of solar cells utilizing a single layer for photovoltaic conversion is given by the single junction Shockley-Queisser limit. In tandem solar cells, a stack of materials with different band gaps contribute to the conversion, enabling tandem cells to exceed the single junction Shockley-Queisser limit. An intriguing variant of this approach is to embed semiconducting nanoparticles in a transparent conducting oxide (TCO) solar cell front contact. This alternative route would enhance the functionality of the TCO layer, allowing it to participate directly in photovoltaic conversion via photon absorption and charge carrier generation in the nanoparticles. Here, we demonstrate the functionalization of ZnO through incorporation of either ZnFe2O4 spinel nanoparticles (NPs) or inversion domain boundaries (IDBs) decorated by Fe. Diffuse reflectance spectroscopy and electron energy loss spectroscopy show that samples containing spinel particles and samples containing IDBs decorated by Fe both display enhanced absorption in the visible range at around 2.0 and 2.6 eV. This striking functional similarity was attributed to the local structural similarity around Fe-ions in spinel ZnFe2O4 and at Fe-decorated basal IDBs. Hence, functional properties of the ZnFe2O4 arise already for the two-dimensional basal IDBs, from which these planar defects behave like two-dimensional spinel-like inclusions in ZnO. Cathodoluminescence spectra reveal an increased luminescence around the band edge of spinel ZnFe2O4 when measuring on the spinel ZnFe2O4 NPs embedded in ZnO, whereas spectra from Fe-decorated IDBs could be deconvoluted into luminescence contributions from bulk ZnO and bulk ZnFe2O4.

The induction of natural competence adapts staphylococcal metabolism to infection

A central question concerning natural competence is why orthologs of competence genes are conserved in non-competent bacterial species, suggesting they have a role other than in transformation. Here we show that competence induction in the human pathogen Staphylococcus aureus occurs in response to ROS and host defenses that compromise bacterial respiration during infection. Bacteria cope with reduced respiration by obtaining energy through fermentation instead. Since fermentation is energetically less efficient than respiration, the energy supply must be assured by increasing the glycolytic flux. The induction of natural competence increases the rate of glycolysis in bacteria that are unable to respire via upregulation of DNA- and glucose-uptake systems. A competent-defective mutant showed no such increase in glycolysis, which negatively affects its survival in both mouse and Galleria infection models. Natural competence foster genetic variability and provides S. aureus with additional nutritional and metabolic possibilities, allowing it to proliferate during infection.

Orthologs of natural competence genes are conserved in non-competent bacterial species, suggesting they have a role other than in transformation. Here, the authors show that competence induction in Staphylococcus aureus occurs in response to reactive oxygen species and host defenses that compromise bacterial respiration during infection, leading to increased DNA and glucose uptake and glycolytic flux.

FRI0215 RESPONSE TO TOCILIZUMAB IN LARGE VESSEL VASCULITIS ACCORDING TO THE EXTENT OF BASELINE 18F-FDG VASCULAR UPTAKE

Background:

18F-FDG PET/CT is useful to establish the presence and extent of large vessel vasculitis (LVV)(1-2).Early therapy is needed to prevent severe complications.Tocilizumab (TCZ) has shown efficacy in LVV(3-5).However, it is unknown if the extent of FDG vascular uptake may influence on clinical response to TCZ

Objectives:

To assess the correlation of the extent of baseline FDG vascular uptake in PET/CT scan with clinical response to TCZ in patients with LVV.

Methods:

Single center study of patients with LVV treated with TCZ who were divided into 2 groups depending on the extent of vascular uptake in baseline PET/CT scan:a) 1-2 affected areasb) ≥affected 3 areas. Vascular uptake was qualitatively assessed by two experienced nuclear medicine physicians in five areas (supraaortic trunks, thoracic aorta, abdominal aorta, iliac and femorotibial arteries). We assessed clinical improvement (no improvement/partial/complete), normalization of CRP (≤0.5mg/dL) and/or ESR (≤ 20 mm/1sth) and reduction of prednisone dose (mg/day).

Results:

30 patients (24 w/6 m); mean age 65.3±10.6 yrs. In baseline PET/CT, vascular uptake was observed in 1 or 2 areas (n=13) and in ≥3 areas (n=17). There was a trend to higher ESR/CRP and shorter evolution of clinical symptoms before TCZ onset in patients with ≥3 affected areas (TABLE 1). Clinical/serological evolution and reduction of prednisone dose is shown in TABLE 2. No statistical differences were found. However, patients with ≥ 3 affected areas tended to experience a slower clinical response.

TABLE 1.1-2 vascular affected areas (n=13)≥3 vascular affected areas (n=17)PDemographic dataAge,mean ± SD66.0 ± 10.864.8 ± 10.70.77Sex (women),n (%)11 (84.6)13 (76.5)0.67Evolution time before TCZ (months),median [IQR]26.0 [3.5-34.0]5.0 [1.5-10.0]0.02Laboratory markersESR (mm/1st h),mean ± SD30.0 ± 27.334.8 ± 27.60.64CRP (mg/dL),mean ± SD1.3 ± 1.21.8 ± 1.70.28Previous treatmentPrednisone dose (mg/day),mean ± SD9.4 ± 6.27.9 ± 6.90.53TCZ therapyIntravenous, n(%)10 (76.9)11 (64.7)0.47Combined with MTX, n(%)6 (46.2)8 (47.1)0.96TABLE 2.1-2 vascular affected areas (n=13)≥ 3 vascular affected areas (n=17)PComplete clinical improvement,n/N (%)6 m11/13 (84.6)12/17 (70.6)0.4312 m12/13 (92.3)13/17 (76.5)0.3618 m10/11 (90.9)11/12 (91.7)0.9924 m8/8 (100)9/10 (90.0)0.99Normalization of ESR and/or CRP,n/N (%)6 m13/13 (100)16/17 (94.1)0.9912 m13/13 (100)16/17 (94.1)0.9918 m11/11 (100)11/12 (91.7)0.9924 m8/8 (100)10/10 (100)0.99Dose of Prednisone (mg/day),median [IQR]6 m5.0 [1.3-5.0]5.0 [0.0-5.0]0.9812 m2.5 [0.0-3.8]0.0 [0.0-5.0]0.9718 m0.0 [0.0-2.5]0.0 [0.0-1.9]0.7224 m0.0 [0.0- 2.2]0.0 [0.0-2.5]0.77

Conclusion:

TCZ therapy was effective in patients with LVV regardless the extent of FDG vascular uptake in baseline PET/CT scan. However, a trend to a slower clinical response was observed in patients with ≥3 affected areas.

References:

[1]Martínez-Rodríguez et al. (18)F-FDG PET/CT in the follow-up of large-vessel vasculitis: A study of 37 consecutive patients. Semin Arthritis Rheum.2018 Feb;47(4):530-537. doi: 10.1016/j.semarthrit.2017.08.009.

[2]Loricera et al. Non-infectious aortitis: a report of 32 cases from a single tertiary centre in a 4-year period and literature review. Clin Exp Rheumatol. 2015 Mar-Apr; 33(2 Suppl 89): S-19-31

[3]Calderón-Goercke M et al. Tocilizumab in giant cell arteritis. Observational, open-label multicenter study of 134 patients in clinical practice. Semin Arthritis Rheum. 2019 Aug; 49(1):126-135. doi: 10.1016/j.semarthrit.2019.01.003

[4]González-Gay MA et al. Current and emerging diagnosis tools and therapeutics for giant cell arteritis. Expert Rev Clin Immunol. 2018 Jul;14(7):593-605. doi: 10.1080/1744666X.2018.1485491.

[5]Loricera et al. Tocilizumab in patients with Takayasu arteritis: a retrospective study and literature review. Clin Exp Rheumatol. 2016 May-Jun;34(3 Suppl 97): S44-53.

Disclosure of Interests:

D. Prieto-Peña: None declared, Monica Calderón-Goercke: None declared, Isabel Martínez-Rodríguez: None declared, Jose Ignacio Banzo: None declared, Patricia Vicente-Gómez: None declared, Javier García-Fernández: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, Roche, Consultant of: Abbvie, Eli Lilly, Pfizer, Roche, Bristol-Myers, Janssen, UCB Pharma and MSD, Speakers bureau: Abbvie, Eli Lilly, Pfizer, Roche, Bristol-Myers, Janssen, UCB Pharma. MSD

THU0297 SERIOUS INFECTIONS IN 134 PATIENTS WITH GIANT CELL ARTERITIS WITH TOCILIZUMAB IN CLINICAL PRACTICE. FREQUENCY, TYPE AND CLINICAL ASSOCIATIONS

Background:

Infections are the most common adverse event of Tocilizumab (TCZ) in Giant Cell Arteritis (GCA). In GiACTA study(1),serious infections were observed in 7% (9.6/100 patient-years) of patients who received TCZ weekly. Randomized clinical trials (RCTs) are conducted under highly standardized design excluding some real-world patients. Therefore, adverse events may be underestimated in RCTs. In our series of real-life, serious infections occurred in 11.9% (10.6/100 patient-years)(2).

Objectives:

In a wide series of GCA of clinical practice treated with TCZ, we assess the frequency, type and predisposing factors of serious infections.

Methods:

Multicenter study of 134 patients diagnosed with GCA, all of them refractory to conventional therapy, treated with TCZ. Serious infection was considered when a life-threatening infection, fatal, or requiring hospitalization occurred, intravenous antibiotics were required, or the infectious process led to persistent or significant disability.

Results:

16 of 134 (11.9%, 10.6/100 patient-years) patients developed serious infections during follow-up. The most frequent infections were pneumonia (n=4), urinary tract infection (n=4), and facial herpes zoster (n=2). At TCZ onset, serious infections were more frequent in older patients (74.3±9.6 vs 72.9±8.7 years), with a longer GCA evolution (20 [4.3-45.6] vs 13 [5-29.3] months), with visual manifestations (43.75% vs 17.8%) and a higher dose of prednisone at TCZ onset (30.4±15.5 vs 21.1±16.1 mg/day) (TABLE). Presence of comorbidities were similar in both groups. 13 of the 16 patients who had infections received a dose of prednisone greater than 15 mg/day (16.3/100 patient-years) compared to 3 patients under treatment with less than 15 mg/day of prednisone (4.2/100 patient-years).

Conclusion:

The age, GCA duration, ocular involvement and the dose of glucocorticoids, at TCZ onset, seem to be predisposing factors related to an increased risk of developing serious infections in GCA patients.

References:

[1]Stone JH, et al. N Engl J Med. 2017; 377:317-28.

[2]Calderón-Goercke M et al. Semin Arthritis Rheum 2019 Aug;49(1): 126-135.

TABLESERIOUS INFECTIONS(n=16)WITHOUT SERIOUS INFECTIONS(n=118)pBASAL FEATURES AT TCZ ONSETGENERAL FEATURES Age, years, mean± SD74.3±9.672.9±8.70.552 Sex, female/male n(%)13/388/300.760 Time from GCA diagnosis to TCZ onset (months), median [IQR]20[4.3-45.6]13[5-29.3]0.604COMORBIDITIES Hypertension, n(%)9(56)86(73)0.551 Diabetes, n(%)3(19)39(33)0.677 Chronic kidney disease, n(%)3(19)27(23)0.512CLINICAL FEATURES OF GCA PMR, n(%)9(56.25)64(54.2)0.879 Aortitis, n(%)5(31.25)53(45)0.301 Visual manifestations, n(%)7(43.75)21(17.8)0.017CORTICOSTEROIDS AT TCZ ONSET Prednisone dose mg/d, mean (SD)30.4±15.521.1±16.10.031

Disclosure of Interests:

Monica Calderón-Goercke: None declared, D. Prieto-Peña: None declared, Santos Castañeda: None declared, Clara Moriano: None declared, Elena Becerra-Fernández: None declared, Marcelino Revenga: None declared, Noelia Alvarez-Rivas: None declared, Carles Galisteo: None declared, Águeda Prior-Español: None declared, E. Galindez: None declared, Cristina Hidalgo: None declared, Sara Manrique Arija: None declared, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Eva Salgado-Pérez: None declared, Vicente Aldasoro Speakers bureau: Roche, Abbvie, MSD, UCB, Pfizer, Menarini, Grunenthal, Gebro, Novartis, Janssen, Ignacio Villa-Blanco Consultant of: UCB, Speakers bureau: Novartis, MSD, Lilly, Susana Romero-Yuste: None declared, J. Narváez: None declared, Catalina Gomez-Arango: None declared, Eva Perez-Pampín: None declared, Rafael Melero: None declared, Francisca Sivera: None declared, Carlos Fernández-Díaz Speakers bureau: Brystol Meyers Squibb, Alejandro Olive: None declared, María Álvarez del Buergo: None declared, Luisa Marena Rojas: None declared, Carlos Fernández-López: None declared, Francisco Navarro: None declared, Enrique Raya: None declared, Beatriz Arca: None declared, Roser Solans-Laqué: None declared, Arantxa Conesa: None declared, Carlos Vázquez: None declared, Jose Andrés Román-Ivorra: None declared, Pau Lluch: None declared, Paloma Vela-Casasempere: None declared, Carmen Torres-Martín: None declared, Juan Carlos Nieto Speakers bureau: Pfizer, Abbvie, MSD, Novartis, Janssen, Lilly, Nordic Pharma, BMS, Gebro, FAES Farma, Roche, Sanofi, Carmen Ordas-Calvo: None declared, Cristina Luna-Gomez: None declared, Francisco J. Toyos Sáenz de Miera: None declared, Nagore Fernández-Llanio: None declared, Antonio García: None declared, Carmen González-Vela: None declared, Javier García-Fernández: None declared, Patricia Vicente-Gómez: None declared, Ángel García-Manzanares: None declared, Norberto Ortego: None declared, Francisco Ortiz-Sanjuán: None declared, Montserrat Corteguera: None declared, J. Luis Hernández: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

SAT0568 PERSISTENT VASCULAR 18F-FDG UPTAKE DESPITE CLINICAL-ANALYTICAL REMISSION IN PATIENTS WITH LARGE VESSEL VASCULITIS UNDER TOCILIZUMAB THERAPY. SINGLE UNIVERSITARY CENTER EXPERIENCE OF 30 PATIENTS

Background:

Tocilizumab (TCZ) has shown efficacy in large vessel vasculitis (LVV)(1-3). Disease activity assessed by laboratory markers (ESR,CRP) may be of less value with TCZ.18F-FDG PET/CT may be useful to monitor LVV disease activity(4-5).

Objectives:

To assessa) evolution of disease activity in LVV treated with TCZ by PET/CT andb) its correlation with clinical/serological markers.

Methods:

Single centre study of 30 patients with refractory LVV treated with TCZ who had a baseline and follow-up PET/CT scan. Vascular uptake was assessed quantitatively and qualitatively. Quantitative analysis was assessed as a target to background ratio (TBR)=SUVmax thoracic aorta/SUVmax aortic vascular pool. For qualitative analysis, FDG uptake at vessel wall was visually grading compared to the liver. We defined a total vascular score which included 5 vascular areas (supra aortic trunks, thoracic, abdominal, iliac and femorotibial arteries) ranging from 0 to 15. Clinical improvement (no improvement/partial/complete), analytical (CRP mg/dL; ESR mm/1sthour) and reduction of prednisone dose (mg/day) were also assessed.

Results:

30 patients (24 w/6 m); mean age 65.3 ± 10.6 yrs. TCZ was started after 6.5 [2.0-20.0] months from LVV diagnosis. Most patients received TCZ as intravenous infusions (70%) and almost half of them (46.7%) received combined therapy with MTX. Clinical/analytical evolution and quantitative/qualitative uptake assessment is shown inTABLE. After a mean follow-up of 37.0±18.5 months, 92.3% of patients experienced complete clinical/analytical improvement. Complete quantitative normalization of vascular uptake (TBR< 1.34) was achieved in 30.8%. Qualitatively, 23.1% of patients showed normalization (total vascular score =0) at the end of the study period.

Conclusion:

Most patients with LVV under TCZ experienced rapid and effective clinical and analytical response. Decrease of vascular uptake was also observed both quantitatively and qualitatively assessed. However, complete normalization of vascular uptake despite clinical remision was only observed in less than one-third of patients.

TABLE.Basal(n=30)6 months(n=9)12-18 months(n=21)>18 months(n=13)Clinical improvementComplete,n (%)7 (77.8)16 (76.2)12 (92.3)Laboratory markersESR (mm/1sth),median [IQR]24.0 [9.8-53.0]2.0 [2.0-3.0] *2.0 [2.0-4.0] *2.0[2.0-3.5] *CRP (mg/dL),median [IQR]1.5 [0.5-2.4]0.1 [0.1-0.2] *0.1 [0.1-0.1] *0.1 [0.1-0.1] *ESR/CRP normalization, n(%)9 (100)21 (100)13 (100)FDG vascular uptakeTBR,mean ± SD1.69 ± 0.521.56±0.41 *1.46±0.16 *1.40 ± 0.18 *Total vascular score,mean ± SD5.0 ± 2.63.7 ± 2.23.3 ± 1.7*2.7 ± 2.4*Quantitative normalization, n(%)4 (44.4)5 (23.8)4 (30.8)Qualitative normalization, n(%)1 (11.1)1 (4.8)3 (23.1)

*test Wilcoxon: p < 0.05. Quantitative normalization when TBR <1.34. Qualitative normalization when total vascular score =0.

References:

[1]Calderón-Goercke M et al. Tocilizumab in giant cell arteritis. Observational, open-label multicenter study of 134 patients in clinical practice. Semin Arthritis Rheum. 2019 Aug; 49(1):126-135. doi: 10.1016/j.semarthrit.2019.01.003.

[2]Loricera et al. Tocilizumab in patients with Takayasu arteritis: a retrospective study and literature review. Clin Exp Rheumatol. 2016 May-Jun;34(3 Suppl 97): S44-53.

[3]González-Gay MA et al. Current and emerging diagnosis tools and therapeutics for giant cell arteritis. Expert Rev Clin Immunol. 2018 Jul;14(7):593-605. doi: 10.1080/1744666X.2018.1485491.

[4]Martínez-Rodríguez et al. (18)F-FDG PET/CT in the follow-up of large-vessel vasculitis: A study of 37 consecutive patients. Semin Arthritis Rheum.2018 Feb;47(4):530-537. doi: 10.1016/j.semarthrit.2017.08.009.

[5]Loricera et al. Non-infectious aortitis: a report of 32 cases from a single tertiary centre in a 4-year period and literature review. Clin Exp Rheumatol. 2015 Mar-Apr; 33(2 Suppl 89): S-19-31.

Disclosure of Interests:

D. Prieto-Peña: None declared, Monica Calderón-Goercke: None declared, Isabel Martínez-Rodríguez: None declared, Jose Ignacio Banzo: None declared, Javier García-Fernández: None declared, Patricia Vicente-Gómez: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, Roche, Consultant of: Abbvie, Eli Lilly, Pfizer, Roche, Bristol-Myers, Janssen, UCB Pharma and MSD, Speakers bureau: Abbvie, Eli Lilly, Pfizer, Roche, Bristol-Myers, Janssen, UCB Pharma. MSD

Recruitment manoeuvres in anaesthesia: How many more excuses are there not to use them?

Pulmonary recruitment manoeuvres (RM) are intended to reopen collapsed lung areas. RMs are present in nature as a physiological mechanism to get a newborn to open their lungs for the first time at birth, and we also use them, in our usual anaesthesiological clinical practice, after induction or during general anaesthesia when a patient is desaturated. However, there is much confusion in clinical practice regarding their safety, the best way to perform them, when to do them, in which patients they are indicated, and in those where they are totally contraindicated. There are important differences between RM in the patient with adult respiratory distress syndrome, and in a healthy patient during general anaesthesia. Our intention is to review, from a clinical and practical point of view, the use of RM, specifically in anaesthesia.

Experience in the management of ECMO therapy as a mortality risk factor

INTRODUCTION

The extracorporeal oxygenation membrane (ECMO) is a system that provides circulatory and respiratory assistance to patients in cardiac or respiratory failure refractory to conventional treatment. It is a therapy with numerous associated complications and high mortality. Multidisciplinary management and experienced teams increase survival.

OBJECTIVE

Our purpose is to evaluate and analyse the effect of the learning curve on mortality.

METHODS

Retrospective and observational study of 31 patients, from January 2012 to December 2015. Patients were separated into 2periods. These periods were divided by the establishment of an ECMO protocol. We compared the quantitative variables by performing the Mann-Whitney U test. For the categorical qualitative variables we performed the chi-square test or Fisher exact statistic as appropriate. The survival curve was computed using the Kaplan-Meier method, and the analysis of statistical significance using the Log-rank test. Data analysis was performed with the STATA programme 14.

RESULTS

Survival curves show the tendency to lower mortality in the subsequent period (P=0.0601). The overall mortality rate in the initial period was higher than in the subsequent period (P=0.042). In another analysis, we compared the characteristics of the 2groups and concluded that they were homogeneous.

CONCLUSION

The degree of experience is an independent factor for mortality. The application of a care protocol is fundamental to facilitate the management of ECMO therapy.

Molecular and functional analysis of the mce4 operon in Mycobacterium smegmatis

Mycobacterium smegmatis contains 6 homologous mce (mammalian cell entry) operons which have been proposed to encode ABC-like import systems. The mce operons encode up to 10 different proteins of unknown function that are not present in conventional ABC transporters. We have analysed the consequences of individually deleting each of the genes of the mce4 operon of M. smegmatis, which mediates the transport of cholesterol. None of the mce4 mutants were able to grow in cholesterol suggesting that all these genes are required for its uptake and that none of them can be replaced by the homologous genes of the other mce operons. This result suggests that different mce operons do not provide redundant capabilities and that M. smegmatis, in contrast with Mycobacterium tuberculosis, is not able to use alternative systems to import cholesterol in the analysed culture conditions. Either deletion of the entire mce4 operon or single point mutations that eliminate the transport function cause a phenotype similar to the one observed in a mutant lacking all 6 mce operons suggesting a pleiotropic role for this system.

Unravelling the pleiotropic role of the MceG ATPase in Mycobacterium smegmatis

The Mce systems are complex ABC transporters that are encoded by different numbers of homologous operons in Actinobacteria. While the four Mce systems of Mycobacterium tuberculosis are all energized by a single ATPase, MceG, each system appears to import different fatty acids or sterols. To explore if this behaviour can be extended to saprophytic mycobacteria, whose more complex genomes encode more Mce systems, we have identified and characterized the MceG orthologue of Mycobacterium smegmatis. This bacterium relies on MceG to energize its six Mce systems that contribute to a variety of cellular functions including sterol uptake and cell envelope maintenance. In the absence of MceG, M. smegmatis was not able to utilize cholesterol or phytosterols as carbon sources implying that this ATPase is necessary to energize the Mce4-sterol transport system. Other phenotypic alterations observed in the ΔMceG mutant, such as cell envelope modifications, suggest a pleiotropic functionality of the Mce systems that are particularly important for stress responses. Several ΔMceG phenotypes were recapitulated in a strain lacking only the unique C-terminal region of MceG, suggesting an important functional or regulatory function for this domain.

Characterization of the KstR2 regulator responsible of the lower cholesterol degradative pathway in Mycobacterium smegmatis

The interaction of KstR2-dependent promoters of the divergon constituted by the MSMEG_6000-5999 and MSMEG_6001-6004 operons of Mycobacterium smegmatis which encode the genes involved in the lower cholesterol degradative pathway has been characterized. Footprint analyses have demonstrated experimentally for the first time that KstR2 specifically binds to an operator region of 29 nucleotides containing the palindromic sequence AAGCAAGNNCTTGCTT. This region overlaps with the -10 and -35 boxes of the putative P(6000) and P(6001) divergent promoters, suggesting that KstR2 represses their transcription by preventing the binding of the ribonucleic acid polymerase. A three-dimensional model of the KstR2 protein revealed a typical TetR-type regulator folding with two domains, a deoxyribonucleic acid (DNA)-binding N-terminal domain and a regulator-binding C-terminal domain composed by three and six helices respectively. KstR2 is an all alpha protein as confirmed by circular dichroism. We have determined that M. smegmatis is able to grow using sitolactone (HIL) as the only carbon source and that this compound induces the kstR2 regulon in vivo. HIL or its open form 5OH-HIP were unable to release in vitro the KstR2-DNA operator interaction, suggesting that 5OH-HIP-CoA or a further derivative would induce the lower cholesterol catabolic pathway.

Effects of fluid load on cardiovascular function during stepwise lung recruitment manoeuvre in healthy dogs

The aim of this study was to evaluate the effects of a stepwise lung recruitment manoeuvre (RM) on cardiac output (CO) in mechanically ventilated dogs, with or without a previous fluid load. Eight healthy adult Beagle dogs were enrolled in a prospective crossover study. Following sedation with dexmedetomidine and methadone, anaesthesia was induced with propofol and maintained with isoflurane. CO (thermodilution method) and direct arterial blood pressure were monitored. The dogs were mechanically ventilated in a volume-controlled mode (tidal volume, VT = 10 mL/kg; positive end-expiratory pressure [PEEP] = 0 cm H2O) until normocapnia was achieved (end tidal CO2 35-45 mmHg). The RM was then performed in a pressure-controlled mode, with progressive increases of the PEEP and end-inspiratory pressure of 5 cm H2O, until 15 cm H2O and 30 cm H2O were reached, respectively. After the RM, the ventilatory mode was returned to volume-control, and the PEEP was sequentially decreased to 10, 5 and 0 cm H2O. Baseline ventilation was maintained for 30 min. Next, 10 mL/kg of lactated Ringer's solution was administered within 10 min, prior to a second RM. The CO was determined before each RM (baseline) and at each pressure step. A repeated measures ANOVA test was used to compare data. Compared to baseline, CO decreased during the RM in both groups. However, there was a significantly higher CO during the second RM at the highest pressure step (P<0.05) and during all decreasing pressure steps (P<0.05). In conclusion, a previous crystalloid fluid load could reduce the impact of a RM on CO in healthy dogs.

Selection of Ceratitis capitata (Diptera: Tephritidae) specific recombinant monoclonal phage display antibodies for prey detection analysis

Several recombinant antibodies against the Mediterranean fruit fly, Ceratitis capitata (Wiedemann) (Diptera: Tephritidae), one of the most important pests in agriculture worldwide, were selected for the first time from a commercial phage display library of human scFv antibodies. The specificity and sensitivity of the selected recombinant antibodies were compared with that of a rabbit polyclonal serum raised in parallel using a wide range of arthropod species as controls. The selected recombinant monoclonal antibodies had a similar or greater specificity when compared with classical monoclonal antibodies. The selected recombinant antibodies were successfully used to detect the target antigen in the gut of predators and the scFv antibodies were sequenced and compared. These results demonstrate the potential for recombinant scFv antibodies to be used as an alternative to the classical monoclonal antibodies or even molecular probes in the post-mortem analysis studies of generalist predators.

[Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment]

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Española de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.

[Usefulness of tranexamic acid in cranial remodeling surgery]

OBJECTIVES

To assess the usefulness of tranexamic acid (TA) in pediatric cranial remodeling surgery, by analyzing its effects on bleeding and transfusion requirements, number of days of cranial drainage required, and time spent in the postoperative recovery unit.

MATERIAL AND METHOD

A single-blind, controlled study was designed with 20 patients (10 cases and 10 controls) randomly assigned to receive or not receive 15 mg/kg of intravenous TA upon anesthetic induction, every 4 hours during surgery, and every 8 hours throughout the 48 hours after surgery. Variables analyzed were results of blood tests, blood loss, volume transfused, time in the recovery unit, and complications related to TA infusion.

RESULTS

The group treated with TA experienced less bleeding during surgery than did the controls (199 +/- 60 vs 290 +/- 43 mL) and had less need of intraoperative (176 +/- 104 vs 206 +/- 70 mL) and postoperative transfusion (9 +/- 28 vs 52 +/- 72 mL) 24 hours after surgery. TA group patients also spent less time in the recovery unit (60 +/- 14 vs 72 +/- 11 hours). Blood test variables in TA-treated children were also better 24 hours after surgery with regard to hemoglobin (12.1 +/- 2 vs 11.6 +/- 1.3 mg/dL) and platelet (261 +/- 68.5 vs 181.6 +/- 58.1 platelets/mm3) concentrations, and cephalin time (33 +/- 12 vs 49 +/- 16 seconds). No complications related to TA treatment were observed.

CONCLUSIONS

TA can reduce perioperative bleeding in the context of pediatric cranial remodeling surgery. TA-treated patients have less need of transfusion and this may reduce the rate of related complications as well a make care more efficient.

[Multicenter study of children's compliance to antibiotic treatment in primary care]

OBJECTIVES

To evaluate the degree of children's adherence to prescription of antibiotics and to determine factors linked to this adherence.

DESIGN

Cross-sectional study, conducted through a telephone survey of parents of the children under study ten to fifteen days after the prescription of the antibiotic.

SETTING

Thirty primary care centres in 6 Spanish provinces.

PATIENTS AND OTHER PARTICIPANTS

Parents or guardians of children from 0 to 10 who attended the primary care centres between October 1998 and January 1999 for treatment of an acute infection and who were prescribed an oral antibiotic treatment with two or more daily doses. Interventions. The measuring instrument was the Morisky-Green test.

MEASUREMENTS AND MAIN RESULTS

2244 cases were studied. 1043 of them complied adequately (46.5%; 95% CI, 44.4-48.5). The factors associated with adherence were children's school situation, the age of parents or carers and the number of daily doses.

CONCLUSIONS

Only half the children complied correctly with the treatment indicated. Pre-school children, those with parents or carers over 40 and those with a prescription of under three daily doses followed the treatment better. These factors need to be borne in mind by paediatricians when they prescribe an antibiotic.

[Hox genes, developmental evolution and the origin of vertebrates]

Homeobox genes comprise a diverse multigene family encoding transcription factors, many of which are key control genes in early development. The roles of several homeobox gene subfamilies have been widely conserved through animal evolution, but there are detailed differences in homeobox gene number, genomic organisation and gene expression between taxa. We have compared Hox and other homebox genes between vertebrates and their closest living relatives, Amphioxus. The results suggest that after evolutionary divergence of these two lineages, homeobox and other genes were duplicated in the lineage leading to vertebrates, but that Amphioxus retained the archetypal homeobox gene organisation. We suggest that prior to vertebrate origins there was an intense phase of gene duplication, followed by recruitment of new developmental control genes to new roles. These genetic changes may have permitted the evolution of novel developmental and anatomical characters, and the origin of vertebrates.

[Physiopathologic implications of the anesthesiologic management of pediatric laparoscopic surgery]

We study gas exchange and hemodynamic repercussions during pediatric laparoscopic surgery. We provided balanced anesthesia with muscle relaxation while ventilation was maintained with FiO2 at 0.4 and flow volume between 10-15 ml/kg-1 during abdominal laparoscopic procedures performed in 10 ASA I-II children (4-14 years). Pneumoperitoneum was produced with CO2 insufflated up to a pressure of 15 mmHg. Airways pressure (PIP), PaO2, PaCO2, heart rate (HR), systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) were measured before insufflation and 5, 30 and 60 minutes afterwards. We calculated the ratio of dead space to flow volume (VD/VT), thoracic distensibility and metabolic production of CO2 (VCO2). Insufflation caused an immediate reduction (29-33%) in dynamic thoracic distensibility (p = 0.0004), but no hypoventilation or increases in VD/VT. The decrease in PaO2 was small (5-6%) but statistically significant (p = 0.0188). Hypercapnia (14-21%) was due to an increase in VCO2 caused by gradual peritoneal absorption of CO2 (24-32%, p = 0.0013). We also found increases in SAP (10%, p = 0.02) and DAP (32%, p = 0.0001) at 5 min, along with an increase in HR (8%, p = 0.0163) at 60 min. Arterial CO2 levels were held within physiological limits by compensatory hyperventilation (+25% of physiological VT). Capnography proved to be an excellent guide. Any clinical repercussion of hemodynamic effects was blocked by a dose of atropine given before insufflation and by the excess loading volume (10 ml/kg of crystalloids). Laparascopic surgery in children diminishes thoracic distensibility and causes hypercapnia, making it necessary to measure PefCO2 to regulate ventilation.