Francisco Javier Álvarez

Comparative study of single-dose and 24-hour multiple-dose antibiotic prophylaxis for cardiac surgery

OBJECTIVE Use of single-dose antibiotic prophylaxis is associated with reduced antibiotic resistance, lower costs, and fewer problems with drug toxicity and superinfections. We tested the hypothesis that single doses of cefazolin are as effective as a 24-hour regimen of cefazolin in preventing surgical site infections in adults undergoing cardiac procedures. METHODS This random, prospective, clinical study included 838 adult patients undergoing elective coronary artery bypass grafting, valve operations, or both. These patients were randomly given a single dose of cefazolin (2 g) or a 24-hour treatment (2-g initial dose, followed by 1 g every 8 hours). Investigators blinded to the drug regimen diagnosed wound infections according to Centers for Disease Control and Prevention criteria. Patient clinical and demographic characteristics were noted, with follow-up for 12 postoperative months. The primary objective was to compare the incidence of surgical infections between groups up to 12 months postoperatively. RESULTS A total of 419 patients received single-dose cefazolin, and another 419 received the 24-hour treatment. Surgical site infection occurred in 35 (8.3%) patients receiving single doses and 15 (3.6%) patients administered the 24-hour treatment (P = .004). We identified no differences between groups for mortality or duration of hospitalization (preoperative hospitalization, intensive care unit stay, and hospitalization after surgical intervention). The microorganisms isolated showed a similar distribution in both groups. The germs isolated were gram-positive cocci in 86% of the surgical site infections. CONCLUSIONS Single-dose cefazolin used as antibiotic prophylaxis in cardiac surgery is associated with a higher surgical site infection rate than the 24-hour, multiple-dose cefazolin regimen.

Identification of liver fibrosis in HIV/HCV-coinfected patients using a simple predictive model based on routine laboratory data

Summary.  We constructed noninvasive models to predict significant fibrosis (F ≥ 2) and advanced fibrosis (F ≥ 3) among human immunodeficiency virus (HIV)/hepatitis C virus (HCV)‐coinfected patients, naïve for anti‐HCV treatment. A total of 296 patients with liver biopsy were randomly assigned to an estimation group (EG = 226; 70%) and a validation group (VG = 70; 30%). We developed the Hospital Gregorio Marañón (HGM)‐1 index, based on platelet count, aspartate aminotransferase (AST) and glucose, to predict F ≥ 2 and the HGM‐2 index, based on platelet count, international normalized ratio, alkaline phosphatase and AST to predict F ≥ 3. The area under the receiver operating characteristic curves (AUROCs) of the HGM‐1 index for the EG and the VG were 0.807 and 0.712 respectively. The AUROCs of the HGM‐2 index for the EG and the VG were 0.844 and 0.815 respectively. With the HGM‐1 index applied to the VG, using best cutoff scores, the negative predictive value (NPV) to exclude F ≥ 2 was 54.5% and the positive predictive value (PPV) to confirm F ≥ 2 was 93.3%. With the HGM‐2 index applied to the VG, using best cutoff scores, the NPV to exclude F ≥ 3 was 92.3, and the PPV to confirm F ≥ 3 was 64.3%. Thus, HGM‐2 accurately predicted F ≥ 3 among HIV/HCV‐coinfected patients. HGM‐1 was less accurate at predicting F ≥ 2.

Evolution of neutrophil apoptosis in septic shock survivors and nonsurvivors

PURPOSE The aims were to analyze the temporal evolution of neutrophil apoptosis, to determine the differences in neutrophil apoptosis among 28-day survivors and nonsurvivors, and to evaluate the use of neutrophil apoptosis as a predictor of mortality in patients with septic shock. MATERIALS AND METHODS Prospective multicenter observational study carried out between July 2006 and June 2009. The staining solution study included 80 patients with septic shock and 25 healthy volunteers. Neutrophil apoptosis was assessed by fluorescein isothiocyanate (FITC)-conjugated annexin V and aminoactinomycin D staining. RESULTS The percentage of neutrophil apoptosis was significantly decreased at 24 hours, 5 days, and 12 days after the diagnosis of septic shock (14.8% ± 13.4%, 13.4% ± 8.4%, and 15.4% ± 12.8%, respectively; P < .0001) compared with the control group (37.6% ± 12.8%). The difference in apoptosis between 28-day surviving and nonsurviving patients was nonsignificant (P > .05). The mortality rate at 28 days was 53.7%. The crude hazard ratio for mortality in patients with septic shock did not differ according to the percentage of apoptosis (hazard ratio, 1.006; 95% confidence interval, 0.98-1.03; P = .60). CONCLUSIONS During the first 12 days of septic shock development, the level of neutrophil apoptosis decreases and does not recover normal values. No differences were observed between surviving and nonsurviving patients.

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

Background and objectives: To analyse the prevalence of positive prick‐tests to all medicaments normally checked in allergy units when a patient is suspected of being allergic to anaesthetics. To establish the degree of agreement between the antecedents of a previous history of an allergic reaction to a medicament and the positive result, or not, to the specific prick‐test for the said medicament. Methods: This was a prospective study, during 2003 and 2004, which analysed 473 patients referred by their doctors to allergy units to make retrospective diagnoses of an allergy to a drug. The prick‐test was done using the undiluted drug. All patients were tested for 41 drugs. These include antibiotics, trimethoprim–sulphamethoxazole, non‐steroidal anti‐inflammatory drugs (NSAIDs) and perioperative drugs (PD): neuromuscular blocking drugs, latex, iodine, local anaesthetics, hypnotics, opioids and coadjuvants. Cohens Kappa Index was used to determine the degree of agreement. Results: 71.5% of patients studied presented a positive prick‐test. The largest number of positive cases was found in antibiotics (56.4%), followed by PD (15.6%), NSAIDs (14.4%) and trimethoprim–sulphamethoxazole (12.7%). Among PD, the highest prevalence of positive prick‐tests was found for neuromuscular blocking drugs (5.3%). Agreement between the substance suspected of causing the allergic reaction and the positive prick‐test was excellent for penicillin (Kappa = 0.74) and other antibiotics (Kappa = 0.721) and good for NSAIDs (Kappa = 0.47) and iodine (Kappa = 0.54). Conclusions: The prevalence of patients with positive prick‐tests to PD occurred in 15.6% in this prospective cohort. Neuromuscular blocking drugs were found to have the highest prevalence of positive prick‐tests. There is positive agreement when the substance responsible for the allergic reaction is suspected, otherwise agreement is low.

Risk Factors for Mediastinitis and Endocarditis after Cardiac Surgery

A prospective open-cohort study was performed in 838 adults undergoing coronary revascularization or valve surgery to define the risk factors for development of surgical site infections. Patients diagnosed with mediastinitis or endocarditis during follow-up were compared with patients with no such infection. After 1 year of follow-up, 22 (2.6%) patients had developed mediastinitis or endocarditis. No preoperative or intraoperative variables were identified as risk factors. By multivariate analysis of postoperative variables, respiratory insufficiency, microorganisms in blood cultures, and intensive care unit stay were independent risk factors for the development of these complications. The type of antibiotic prophylaxis had no influence on the incidence of organ or space infections after cardiac surgery.

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

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

Efecto de la simvastatina en la concentración de las proteínas de fase aguda después de la cirugía cardíaca

Fundamento y objetivo Existe informacion contradictoria referente a que los efectos pleiotropicos de las estatinas mejoran la morbimortalidad de las intervenciones con circulacion extracorporea, ya que reducen las concentraciones plasmaticas de proteinas de fase aguda. Pacientes y metodo Se ha realizado un estudio prospectivo y aleatorizado que incluyo a 44 pacientes a los que se efectuo derivacion aortocoronaria con circulacion extracorporea. Se dividieron en 2 grupos: A (n = 22), formado por pacientes que tomaron simvastatina, y B (n = 22), que fue el grupo control. Se determinaron las concentraciones plasmaticas de proteinas de fase aguda (interleucina 6, fraccion C4 del complemento y proteina C reactiva). Resultados No se observaron diferencias significativas entre ambos grupos en las concentraciones de proteinas de fase aguda ni en las complicaciones postoperatorias. En ambos grupos, las concentraciones maximas de interleucina 6 se observaron a las 6 h de la cirugia y las de proteina C reactiva a las 48 h. Las concentraciones de C4 descendieron al inicio de la derivacion cardiopulmonar y volvieron a la normalidad a las 48 h. Conclusiones La administracion de simvastatina a pacientes intervenidos de revascularizacion miocardica con circulacion extracorporea no modifica las concentraciones plasmaticas de proteinas de fase aguda.

Development of the Post Cardiac Surgery (POCAS) prognostic score

IntroductionThe risk of mortality in cardiac surgery is generally evaluated using preoperative risk-scale models. However, intraoperative factors may change the risk factors of patients, and the organism functionality parameters determined upon ICU admittance could therefore be more relevant in deciding operative mortality. The goals of this study were to find associations between the general parameters of organism functionality upon ICU admission and the operative mortality following cardiac operations, to develop a Post Cardiac Surgery (POCAS) Scale to define operative risk categories and to validate an operative mortality risk score.MethodsWe conducted a prospective study, including 920 patients who had undergone cardiac surgery with cardiopulmonary bypass. Several parameters recorded on their ICU admission were explored, looking for a univariate and multivariate association with in-hospital mortality (90 days). In-hospital mortality was 9%. Four independent factors were included in the POCAS mortality risk model: mean arterial pressure, bicarbonate, lactate and the International Normalized Ratio (INR). The POCAS scale was compared with four other risk scores in the validation series.ResultsIn-hospital mortality (90 days) was 9%. Four independent factors were included in the POCAS mortality risk model: mean arterial pressure, bicarbonate ratio, lactate ratio and the INR. The POCAS scale was compared with four other risk scores in the validation series. Discriminatory power (accuracy) was defined with a receiver-operating characteristics (ROC) analysis. The best accuracy in predicting in-hospital mortality (90 days) was achieved by POCAS. The areas under the ROC curves of the different systems analyzed were 0.890 (POCAS), followed by 0.847 (Simplified Acute Physiology Score (SAP II)), 0.825 (Sepsis-related Organ Failure Assessment (SOFA)), 0.768 (Acute Physiology and Chronic Health Evaluation (APACHE II)), 0.754 (logistic EuroSCORE), 0.714 (standard EuroSCORE) and 0.699 (Age, Creatinine, Ejection Fraction (ACEF) score).ConclusionsOur new system to predict the operative mortality risk of patients undergoing cardiac surgery is better than others used for this purpose (SAP II, SOFA, APACHE II, logistic EuroSCORE, standard EuroSCORE, and ACEF score). Moreover, it is an easy-to-use tool since it only requires four risk factors for its calculation.

Intraoperative PaO2 is not related to the development of surgical site infections after major cardiac surgery

BackgroundThe perioperative use of high inspired oxygen fraction (FIO2) for preventing surgical site infections (SSIs) has demonstrated a reduction in their incidence in some types of surgery however there exist some discrepancies in this respect. The aim of this study was to analyze the relationship between PaO2 values and SSIs in cardiac patients.MethodsWe designed a prospective study in which 1,024 patients undergoing cardiac surgery were analyzed.ResultsSSIs were observed in 5.3% of patients. There was not significant difference in mortality at 30 days between patients with and without SSIs. In the uni and multivariate analysis no differences in function of the inspired oxygen fraction administrated were observed.ConclusionsWe observed that the PaO2 in adult cardiac surgery patients was not related to SSI rate.

Accident Rates for Drug-Dependent Patients in Treatment for Substance Dependence: A Pilot Trial

Objectives: To analyze accident rates among drug-dependent patients before and after treatment for substance dependence. Methods: Self-reported lifetime data and data from the year prior to the start of treatment were analyzed from a cohort including 53 drug-dependent patients, 48 men and 5 women, who had started treatment for substance dependence in an outpatient treatment center in Valladolid, Spain. We also obtained prospective information about treatment dropout and accident rates in the 3-month follow-up period after the start of drug-dependency treatment. Results: Twenty-two percent of drug-dependent patients had an accident in the year prior to starting treatment, and 64.2 percent had an accident in his or her lifetime. Road traffic accidents were the most frequent, with 11.3 percent of patients reporting at least one in the prior year and 45.3 percent reporting at least one road traffic accident in his or her lifetime. Furthermore, drug-dependent patients were frequently under the influence of drugs when driving (13.2%), as well as when performing dangerous activities at work (11.3%), at home (9.4%), and during sporting activities (5.7%) in the year prior to starting treatment. Of the 30 patients who were still undergoing treatment after 3 months, 2 had had accidents during this period (6.6%), one occurring at work and the other at home. Conclusions: Accident involvement, and especially involvement in road traffic accidents, was common among drug-dependent patients. Many accidents occurred in the year prior to treatment initiation. Furthermore, drug-dependent patients often undertook risky activities while under the influence of drugs. There is a need to implement accident prevention strategies, especially strategies that target road traffic accidents, in treatment programs for drug-dependent patients.