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Gerard Espinosa

Publications and source records attributed to Gerard Espinosa.

At least 19 recordsLinked to original sources
PubMed2007

Catastrophic antiphospholipid syndrome during pregnancy and puerperium: maternal and fetal characteristics of 15 cases.

BACKGROUND: The catastrophic variant of the antiphospholipid syndrome (APS) is a life-threatening form of presentation of this syndrome that can be triggered by several factors. AIM: To describe the characteristics of patients who developed catastrophic APS triggered during pregnancy and puerperium. METHODS: A review of the first 255 cases collected in the website-based "CAPS Registry" was undertaken. Three new and unpublished cases of catastrophic APS developed during pregnancy and puerperium were added. RESULTS: Fifteen cases were identified. The mean (range) age was 27 (17-38) years. Most patients had a previous unsuccessful obstetric history. In 7 of 14 (50%) cases with available medical history, the catastrophic APS appeared during pregnancy, in 6 (43%) during the puerperium and in 1 (7%) after curettage for a fetal death. The main clinical and serological characteristics were similar to those patients with catastrophic APS triggered by other factors, except for a history of a higher prevalence of previous abortions (p<0.01). Several specific features were found, including the HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome in 8 (53%) patients, placental infarctions in 4 (27%) patients, and pelvic vein thrombosis and myometrium thrombotic microangiopathy in 1 (7%) patient each. Mortality rate was high for the mothers (46%), and for the babies (54%). CONCLUSIONS: It is important to consider the possibility of the development of catastrophic APS in those patients with signs of HELLP syndrome and multiorgan failure during pregnancy or puerperium, especially in those patients with previous history of abortions and/or thrombosis.

Adolescent↗
PubMed2007

Intestinal involvement secondary to the antiphospholipid syndrome (APS): clinical and immunologic characteristics of 97 patients: comparison of classic and catastrophic APS.

OBJECTIVE: To analyze the clinical and laboratory characteristics of 97 patients with intestinal involvement secondary to the antiphospholipid syndrome (APS) (37 patients with classic APS and 60 with catastrophic APS). METHODS: A computer-assisted (PubMed) search of the literature was performed to identify all cases of intestinal involvement associated with the APS from 1983 to December 2005. In addition, we analyzed the web-site-based international registry of patients with catastrophic APS ("CAPS Registry"). RESULTS: There were no differences in distribution by gender, mean age, and previous clinical manifestations of APS between the 2 groups. The prevalence of abdominal pain as the presenting manifestation of intestinal ischemia was higher in patients with classic APS (76% versus 37%; P < 0.005). The main difference in histopathologic findings between the 2 groups was the higher rate of microthrombosis in patients with catastrophic APS (75% versus 4%; P < 0.0005). The mortality rate was higher in patients with catastrophic APS (55% versus 17%; P < 0.0005). Follow-up was available in 22 patients with classical APS: 17 of them were discharged on oral anticoagulation and with a mean follow-up of 13 months (range, 1 to 48); all were in good health without the development of new thrombotic events. CONCLUSIONS: Intestinal involvement, although infrequent, is an important complication in patients with APS, especially in those with catastrophic APS. This would support the need for systematic screening for aPL in all cases of mesenteric thrombosis or ischemic colitis without clear underlying predisposing factors, and for systematic screening procedures in all classic APS patients complaining of abdominal pain.

Adolescent↗
PubMed2006

[Behçet disease].

Explore the source record for details and available documents.

Behcet Syndrome↗
PubMed2006

Mortality in the catastrophic antiphospholipid syndrome: causes of death and prognostic factors.

In order to know the causes of death and the prognostic factors, our group analyzed 250 patients included until February 2005 in the web-site based international registry of patients with catastrophic antiphospholipid syndrome (APS) ("CAPS Registry") (http://www.med.ub.es/MIMMUN/FORUM/CAPS.HTM). Cerebral involvement, mainly consisting of stroke, followed by cardiac involvement and infections were considered the main causes of death in patients with catastrophic APS. The presence of systemic lupus erythematosus was related with higher mortality. According to the results of this analysis, anticoagulation plus steroids plus plasma exchange should be the first line of therapy in patients with catastrophic APS.

Age of Onset↗
PubMed2006

Lessons from the catastrophic antiphospholipid syndrome (CAPS) registry.

Although less than 1% of patients with the antiphospholipid syndrome (APS) develop the catastrophic variant, its potentially lethal outcome emphasizes its importance in clinical medicine today. However, the rarity of this variant makes it extraordinarily difficult to study in any systematic way. In order to put together all the published case reports as well as the new diagnosed cases from all over the world, an international registry of patients with catastrophic APS ("CAPS Registry") was created in 2000 by the European Forum on Antiphospholipid Antibodies. Currently, it documents the entire clinical, laboratory and therapeutic data of more than 300 patients whose data has been fully registered. This registry can be freely consulted at the Internet (www.med.ub.es/MIMMUN/FORUM/CAPS.HTM) and it is expected that the periodical analysis of these data will allow us to increase our knowledge of this condition.

Antiphospholipid Syndrome↗
PubMed2006

Pregnancy and puerperium are high susceptibility periods for the development of catastrophic antiphospholipid syndrome.

It is well known that antiphospholipid syndrome (APS) is associated with recurrent pregnancies losses, but is also associated with other obstetric features such as preeclampsia, uteroplacental insufficiency and preterm birth. Pregnancy is a hypercoagulable state than can be complicated by thrombosis, especially in those patients with an underlying thrombophilic disorder. Catastrophic APS is a rare form of presentation of the APS. Several trigger factors have been related with the catastrophic APS, including infections, anticoagulation withdrawal, surgery, neoplasms and lupus "flares". In around 6% of the cases, the catastrophic APS can appear during pregnancy or puerperium. We review this specific subset of the catastrophic APS and propose a therapeutical approach for this particular situation.

Antiphospholipid Syndrome↗
PubMed2006

Laboratory studies on pathophysiology of the catastrophic antiphospholipid syndrome.

The 'catastrophic' variant of the antiphospholipid syndrome (APS) is characterized by a diffuse thrombotic microvasculopathy. In contrast to the classical APS, single venous or arterial medium-to-large blood vessel occlusions are uncommon. The mechanisms of catastrophic APS are not clearly understood. In addition, there are no studies on pathophysiologic mechanisms of catastrophic APS. The clinical manifestations of catastrophic APS probably depend on (a) the organs affected by the thrombotic events and extent of the thrombosis and (b) manifestations of the systemic inflammatory response syndrome which are presumed to be due to excessive cytokine release from affected and necrotic tissues. The evident relationship between APS and infection may enable us to explain the development of catastrophic APS using the sepsis model. This is because catastrophic APS is characterized by multiple microvascular thrombotic events, of rapid onset, and causing multiorgan failure, a picture suggestive of septic shock, in which, there is a massive, acute inflammatory response.

Antiphospholipid Syndrome↗
PubMed2006

[Direct discharge from triage in emergency departments: assessment, risks and patient satisfaction].

BACKGROUND AND OBJECTIVE: After triage assessment, some hospitals refer emergency department (ED) patients with minor chief complaints to off-site clinics. The potential for 2 different referral models introduced in 2 urban hospitals was assessed, as well as the suitability of this measure. PATIENTS AND METHOD: After triage assessment, patients with minor complaints were identified. ED from Hospital Clínic of Barcelona (HCB) proposed that these patients should be referred to a hospital affiliated off-site clinic, whereas ED from Hospital Mútua de Terrassa (HMT) tried to refer such patients to their primary care setting. Within a year, we assessed on both ED the following items: number of arrivals, percentage of proposed referrals (PR), percentage of accepted referrals (AR), percentage of carried-out referrals (CR: patients who, once discharged, really attended the other setting), and percentage of returned referrals (RR) to the ED, as well as return reasons, and the percentage of returned patients finally admitted. The degree of patient satisfaction was evaluated by means of a telephone survey. RESULTS: From both ED, 44,764 arrivals and 7,297 (16.3%) PR were registered. The percentage of AR and CR was 94.3% and 75.3%, respectively. The percentage of PR from HMT was higher (18.7% vs 13.1%; p < 0.001), yet HCB obtained a greater percentage of AR (98.9% vs 92%, p < 0.001) and CR (93.7% vs 65%; p < 0.001). The percentage of RR from both ED was 1.5% (2.8% vs 0.4%; p < 0.001). Among returned patients, 12 of them (0.17% respect to AR) were finally admitted. Only 41% of patients who were found to be eligible for direct discharge would have agreed with being referred to another clinical setting, but after the experience, up to 93% of them said they would go through it again. HMT gave referral information to patients faster than HCB (p < 0.05), but HCB got a better model evaluation (p < 0.01), a greater medical complaint solution (p < 0.05), and generated a smaller number of subsequent consultations (p < 0.05). CONCLUSIONS: After a rapid triage assessment, a percentage of patients arriving on EDs may be directly and safely discharged and referred to other clinical settings. This is achieved by both proposed models without additional risks for patients. However, patients feel more satisfied with an hospital-affiliated off-site clinic instead of their primary care setting.

Adult↗
PubMed2006

Mortality in the catastrophic antiphospholipid syndrome: causes of death and prognostic factors in a series of 250 patients.

OBJECTIVE: To assess the main causes of death and the prognostic factors that influence mortality in patients with the catastrophic antiphospholipid syndrome (CAPS). METHODS: We analyzed the case reports of 250 patients included in the CAPS Registry up to February 2005. To identify prognostic factors for CAPS, we compared the main clinical and immunologic features and the types of treatment in the patients who died with those features in the patients who survived. RESULTS: Recovery occurred in 56% of the episodes of CAPS and death occurred in 44%. Cerebral involvement, consisting mainly of stroke, cerebral hemorrhage, and encephalopathy, was considered the main cause of death, being present in 27.2% of patients, followed by cardiac involvement (19.8%) and infection (19.8%). The only factor we identified that was prognostic of a higher mortality rate was the presence of systemic lupus erythematosus (SLE). A higher recovery rate was associated with combined treatment with anticoagulants (ACs) plus corticosteroids (CS) plus plasma exchange (PE) (77.8%), followed by ACs plus CS plus PE and/or intravenous immunoglobulins (69%). In contrast, concomitant treatment with cyclophosphamide did not demonstrate additional benefit. CONCLUSION: Cerebral involvement (mainly consisting of stroke), cardiac involvement, and infections were considered the main causes of death in patients with CAPS. The presence of SLE was related to a higher mortality rate. According to the results of the present study, ACs plus CS plus PE should be the first line of therapy in patients with CAPS.

Adult↗
PubMed2006

Antiphospholipid antibodies associated with malignancies: clinical and pathological characteristics of 120 patients.

OBJECTIVE: To describe the different types of malignancies associated with antiphospholipid antibodies (aPL). METHODS: We performed a computer-assisted (MEDLINE, National Library of Medicine, Bethesda, MD) search of the literature from 1966 to 2003 to identify all cases of malignancies having aPL. RESULTS: One hundred twenty patients were found. The mean age was 56+/-17 years (range 5 to 88). Sixty-two (52%) patients were men and 58 (48%) were women. A heterogeneous group of malignancies were found. Regarding hematological malignancies, 10 (8%) patients suffered from B-cell lymphoma, 8 (7%) from spleen lymphoma, 7 (6%) from chronic myeloid leukemia, and 6 (5%) from non-Hodgkin's lymphoma (NHL). Regarding solid tumors, renal cell carcinoma was diagnosed in 7 (6%) patients, primary tumor with unknown origin in 7 (6%), lung adenocarcinoma in 6 (5%), breast carcinoma in 6 (5%), and melanoma in 6 (5%). The main aPL-related manifestations were thrombocytopenia (25%), cerebrovascular accidents (24%), deep vein thrombosis (19%), pulmonary embolism (15%), and heart valve lesions (9%). In 17 cases, catastrophic antiphospholipid syndrome was considered to be triggered by the malignancy. Seventy-one (63%) of 113 patients recovered or are still alive after cancer treatment. Twenty-three (35%) of 65 patients achieved aPL remission after proper treatment of the malignancy. CONCLUSIONS: It is important to bear in mind, especially in elderly patients, that thrombotic events associated with aPL can be the first manifestation of malignancy. At the same time, the presence of aPL in patients with malignancies has important implications in their treatment and prognosis.

Antibodies, Antiphospholipid↗
PubMed2005

Severe valvular regurgitation and antiphospholipid antibodies in systemic lupus erythematosus: a prospective, long-term, followup study.

OBJECTIVE: To assess whether the presence of antiphospholipid antibodies is related to the incidence and progression of severe valvular dysfunction and the need for valve replacement in patients with systemic lupus erythematosus (SLE). METHODS: In this prospective, long-term followup study, the initial echocardiographic findings in a cohort of 61 consecutive SLE patients were compared with those of 40 matched controls. All patients were serially evaluated for 14 +/- 3 years and had a followup echocardiogram 8 +/- 3 years after the initial evaluation. Serial determinations of anticardiolipin antibodies and lupus anticoagulant were performed in all cases. RESULTS: The number of SLE patients with valvular abnormalities increased from 39% to 73% between the initial and the followup echocardiography, but only 7 patients (12%) developed severe valvular regurgitation. Severe valvular regurgitation was significantly associated with the presence of high levels of IgG anticardiolipin antibodies (P = 0.001). The combined incidence of stroke, peripheral embolism, need for valve surgery, and death was 86% in patients with severe valvular regurgitation, compared with 25% in those without (P = 0.003). CONCLUSION: In SLE patients, the presence of high levels of IgG anticardiolipin antibodies is associated with the development of severe valvular regurgitation and with a high incidence of thromboembolic events and the need for valvular surgery.

Adolescent↗
PubMed2005

[Basic cardiopulmonary resuscitation program for high school students (PROCES). Results from the pilot program].

BACKGROUND AND OBJECTIVE: The PROCES (Programa de Reanimació Cardiopulmonar Orientat a Centres d'Ensenyament Secundari) program is aimed at teaching basic cardiopulmonary resuscitation (b-CPR) to teenagers within high school. Our aim was to analyze the results obtained from the pilot program. SUBJECTS AND METHOD: PROCES was splitted in 7 sessions: 5 of them (5 hours) were taught by teachers at high school and 2 of them (4 hours, including how to perform b-CPR) were taught by emergency physicians. To assess the degree of students' learning, they were administered a 20-question test before and after the program. Epidemiological characteristics and students' opinions (all them were requested to rate the program from 0 to 10) were also collected. RESULTS: Students were 14 years-old in 38%, 15 in 38% and 16 or more in 24%. Before PROCES, the mean mark (over 20 points) was 8.5 (2.4). After PROCES, marks improved up to 13.5 (3.2) (p < 0.001). Participants who had previously taken a first-aid course or were in the 4th course obtained significantly better marks than the rest. These differences disappeared after PROCES completion. Students rated the theoretical part as 7.9 (1.1), the skill part as 8.2 (1.2), and the emergency physicians classes as 8.4 (1.1). CONCLUSIONS: PROCES is an useful tool for teaching and improving teenagers' knowledge and skills in b-CPR, with no exceptions associated with teenagers' characteristics.

Adolescent↗
PubMed2003

[Emergency department overcrowding: quantification of associated factors].

BACKGROUND AND OBJECTIVE: Emergency department (ED) overcrowding has been increasing over the last years. The aims are to define ED overcrowding, and to determine and quantify which factors explain it. PATIENTS AND METHOD: For 3 consecutive weeks throughout 3 years (2000-2002), we recorded every 3-hour period, the arrivals, the occupancy rate (OR) of patients in ED, in first aid area (FAA), and in observation area (OA) according to the reason for their stay. The data was subjected to multiple logistic regression analysis including as a dependent variable non overcrowding/overcrowding for each area (ED, FAA, and OA). Overcrowding was defined as an OR >= 100%. Models from the three areas were calculated according to goodness of fit and were discriminated by ROC methodology. Models were set up after randomizing data in two groups: selection set (88% of data) and validation set (12% of data). RESULTS: Variables associated with overcrowding in the ED model were OR of patients waiting for test results, for a bed going to be left, to find a bed, for test performed out of ED, and for outcome. In the FAA model, they were OR of patients being seen, and waiting for test results. Finally, in the OA model they were OR of patients waiting for a bed going to be left, to find a bed, for test performed out of ED, and for outcome. For all models sensitivity and specificity were greater than 85%, with a ROC area greater than 0.97. We did not find any relationship between number of arrivals and overcrowding for none model. Results were corroborated on the validation data set. CONCLUSIONS: Patients remaining in the ED due to factors related to both hospital (waiting for a bed going to be left, or to find a bed), and ED itself (waiting for outcome) are the main reason for ED overcrowding.

Emergency Service, Hospital↗
PubMed2003

Sedation for cardioversion in the emergency department: analysis of effectiveness in four protocols.

STUDY OBJECTIVE: We compare effectiveness, adverse effects, and recovery times of propofol, etomidate, and midazolam (with and without flumazenil) for cardioversion in the emergency department (ED). METHODS: Thirty-two hemodynamically stable adult patients undergoing cardioversion in the ED were randomly assigned to receive etomidate (n=9), propofol (n=9), midazolam (n=8), or midazolam followed by flumazenil (n=6). For all patients, we measured induction time, awakening time, total recuperation time, global time, and adverse effects. Arterial pressure, cardiac and respiratory rate, and peripheral oxygen saturation were monitored throughout the procedure. Descriptive and nonparametric tests were used. RESULTS: Demographic data were similar in all groups. Deep sedation and successful cardioversion were achieved in all cases. Hemodynamic assessment at baseline, after induction, after cardioversion, and at recovery demonstrated no significant difference between the 4 groups. Induction time was short in all groups. Awakening time was longer in the midazolam group (median 21 minutes, range 1 to 42 minutes) compared with that of the other groups (etomidate group: median 9.5 minutes, range 5 to 11 minutes; propofol group: median 8 minutes, range 3 to 15 minutes; midazolam/flumazenil group: median 3 minutes, range 2 to 5 minutes), and the same occurred with total recuperation time (etomidate group: median 14 minutes, range 5 to 20 minutes; propofol group: median 10 minutes, range 5 to 15 minutes; midazolam group: median 45 minutes, range 20 to 60 minutes; midazolam/flumazenil group: median 5 minutes, range 2 to 90 minutes). All patients in the midazolam/flumazenil group but 1 became resedated after flumazenil was discontinued. Four patients who had received etomidate exhibited myoclonus, which was pronounced and seizure-like in 1 case. CONCLUSION: Four sedative regimens (propofol, etomidate, midazolam, and midazolam/flumazenil) were uniformly effective in facilitating ED cardioversion in hemodynamically stable adults. Propofol was well tolerated and lacked the myoclonus, prolonged sedation, and resedation noted with the latter 3 respective groups. Larger studies are needed to generalize these conclusions.

Adolescent↗
PubMed2003

Antiphospholipid syndrome: pathogenic mechanisms.

Despite the strong association between antiphospholipid antibodies (aPL) and thrombosis, the pathogenic role of aPL in the development of thrombosis has not been fully elucidated. Proposed pathophysiological mechanisms may be categorized into two types. First, aPL may act in vivo by disrupting the kinetics of the normal procoagulant and anticoagulant reactions occurring on cell membranes. Second, aPL may stimulate certain cells thereby altering the expression and secretion of various molecules. In this article, we review the mechanisms by which aPL may develop thrombotic events.

Animals↗
PubMed2003

Adrenal involvement in the antiphospholipid syndrome: clinical and immunologic characteristics of 86 patients.

To describe the clinical and immunologic characteristics of patients with adrenal involvement and antiphospholipid syndrome (APS), we conducted a computer-assisted (PubMed) search of the literature to identify all cases of primary adrenal insufficiency associated with antiphospholipid antibodies published in English, French, and Spanish from 1983 (when APS was first defined) through March 2002. We reviewed 86 patients (80 from the literature plus 6 from our cohort); 55% were male, and the mean age at presentation was 43 +/- 16 years. Sixty-one (71%) patients had primary APS, and 14 (16%) had systemic lupus erythematosus. In 31 (36%) patients, adrenal insufficiency was the first clinical manifestation of APS. Abdominal pain was present in 55% of patients, followed by hypotension (54%), fever (40%), nausea or vomiting (31%), weakness or fatigue (31%), and lethargy or altered mental status (19%). The main finding in imaging techniques was compatible with adrenal hemorrhage (59%) and in histopathologic study was a hemorrhagic infarction with vessel thrombosis (55%). Lupus anticoagulant was detected in 97% of patients and the anticardiolipin antibodies titer was positive in 93% of patients. Most patients (95%) were positive for the IgG isotype of anticardiolipin antibodies, whereas 40% were positive for the IgM isotype. Baseline cortisol levels were decreased in 98% of patients, ACTH hormone levels were increased in 96% of patients, and the cosyntropin stimulation test was positive in 100% of patients tested. Steroid replacement therapy was the most frequent treatment (84%), followed by anticoagulation (52%) and aspirin (6%). Thirty-two of 35 (91%) patients with prolonged anticoagulant therapy were in good health with a mean follow-up of 25 months, whereas 25 of the 69 (36%) patients with outcome data available had died. The results of the present review stress the clinical importance of systematic screening for lupus anticoagulant and anticardiolipin antibodies in all cases of adrenal hemorrhage or infarction. An initial screening for hypoadrenalism is mandatory in any antiphospholipid antibody-positive patient who complains of abdominal pain and undue weakness or asthenia.

Abdominal Pain↗
PubMed2002

Effects of beta2-glycoprotein I and monoclonal anticardiolipin antibodies in platelet interaction with subendothelium under flow conditions.

OBJECTIVE: To evaluate whether the effect of human monoclonal anticardiolipin antibodies (aCL) on platelet interaction with the subendothelium under flow conditions is dependent on beta(2)-glycoprotein I (beta(2)GPI). METHODS: Three monoclonal IgM aCL with anti-beta(2)GPI activity (TM1B3, GR1D5, and EY2C9) obtained from patients with antiphospholipid syndrome, a monoclonal aCL with lupus anticoagulant activity but without anti-beta(2)GPI activity (FRO) obtained from a patient with a splenic lymphoma, and a control monoclonal IgM without aCL activity were used. TM1B3, GR1D5, EY2C9, FRO, and control IgM (30 microg/ml) were added to reconstituted blood containing gel-filtered platelets (200 x 10(9)/liter), factor VIII (100 units/dl), and fibrinogen (1.5 gm/liter). Samples were perfused (wall-shear rate 800 seconds(-1)), with and without the addition of purified beta(2)GPI (20 microg/ml), through annular chambers containing collagen-rich denuded vascular segments, and the percentages of surface covered by platelets and by thrombi were evaluated. RESULTS: No differences in the percentages of surface covered by platelets and by thrombi were observed among samples with TM1B3, GR1D5, EY2C9, FRO, and control IgM added when reconstituted blood samples without beta(2)GPI were used. However, a significant increase in the percentage of surface covered by platelets was observed in the presence of TM1B3, GR1D5, and EY2C9 but not in the presence of FRO when samples containing beta(2)GPI were used. Increased thrombi formation was induced by TM1B3 and GR1D5 but not by EY2C9 or FRO in samples with added beta(2)GPI. CONCLUSION: Monoclonal aCL require anti-beta(2)GPI activity to promote platelet interaction with the subendothelium under flow conditions.

Antibodies, Anticardiolipin↗