Extended prophylaxis with bemiparin for the prevention of venous thromboembolism after abdominal or pelvic surgery for cancer: the CANBESURE randomized study.

BACKGROUND: There is not enough clinical evidence to make a strong recommendation on the optimal duration of thromboprophylaxis using low-molecular weight heparins (LMWH) in patients undergoing major cancer surgery. PATIENTS AND METHODS: CANBESURE is a randomized, double-blind study which enrolled patients admitted for abdominal or pelvic surgery for cancer. They received 3500 IU of bemiparin subcutaneously once daily for 8 days and were then randomized to receive either bemiparin or placebo for 20 additional days. Bilateral venography was performed after 20 days and evaluated blinded. The primary efficacy outcome was the composite of deep vein thrombosis (DVT), non-fatal pulmonary embolism (PE) and all-cause mortality at the end of double-blind period. Major venous thromboembolism (proximal deep-vein thrombosis, non-fatal pulmonary embolism and venous thromboembolism-related deaths) was also evaluated. The primary safety outcome was major bleeding. RESULTS: Six hundred and twenty-five and 488 patients were included in the safety and main efficacy analyzes, respectively. The primary efficacy outcome occurred in 25 out of 248 patients (10.1%) in the bemiparin group and 32 out of 240 (13.3%) in the placebo group (relative risk reduction 24.4%; 95% CI: -23.7-53.8%; P = 0.26). At the end of double-blind period, major venous thromboembolism occurred in 2 (0.8%) and 11 (4.6%) patients, respectively (relative risk reduction 82.4%; 95% CI: 21.5-96.1%; P = 0.010). No significant difference was found in major bleedings. CONCLUSIONS: Four weeks compared with 1 week of prophylaxis with bemiparin after abdominal or pelvic cancer surgery did not significantly reduce the primary efficacy outcome, but decreased major venous thromboembolism (VTE) without increasing hemorrhagic complications.

El Proyecto MADAI: un estudio epidemiológico sobre el abordaje y manejo del dolor agudo periquirúrgico / MADAI project: an epidemiologic study about the perioperative pain tnanagetnent and treattnent

Objetivo. Obtener información descriptiva sobre el abordaje y el manejo del paciente con dolor agudo periquirúrgico tratado con analgésicos parenterales en el ámbito hospitalario. Metodología. Estudio epidemiológico, descriptivo, multicéntrico. Pacientes ingresados en los servicios de cirugía general, torácica, cardiovascular, angiología y cirugía vascular, ginecología, traumatología y urología. Resultados. Participaron 76 hospitales distribuidos por las diferentes comunidades autónomas y un total de 439 investigadores. Se evaluaron 1972 pacientes de los que el 43.9% y 25.5%, respectivamente pertenecieron a los servicios de cirugía general y traumatología. El 52.8% de los pacientes tenían más de 60 años, un 31.2 % no presentaron ninguna enfermedad concomitante, el 36.7% padecían hipertensión y un 16.5% diabetes. En el 5.8% de los pacientes se utilizaron escalas para valorar la intensidad del dolor al ingreso. En las sucesivas visitas, este porcentaje oscila entre el 10 % y el 15%. En el postoperatorio, los principales analgésicos administrados son los AINE (sobre todo el metamizol, que utilizan del 63.6% al 40.5% del total de pacientes del estudio) y el paracetamol, que utilizan el 41.3% a las 0-12horas y el 27% el día 4. El porcentaje que recibe medicación de rescate va disminuyendo, desde el primer control (25.7%), al del cuarto día (6%), siendo la medicación más utilizada el paracetamol. Conclusiones. A pesar de que en el ámbito de la cirugía se considera importante el tratamiento del dolor, la utilización de protocolos no es habitual. La elaboración y utilización de guías terapéuticas para el tratamiento del dolor peri quirúrgico podría mejorar el confort del paciente y su recuperación (AU)

Objective. To obtain descriptive information about patient treatment with acute perioperative pain receiving parenteral analgesics in hospital environments. Methodology. Epidetniologic descriptive multicentre study. Patients admitted in the following Surgery services: General, Thoracic, Cardiovascular, Angiology, Gynaecology, Orthopaedic and Urology. Results. Participation of 76 hospitals, distributed along the country; and 439 investigators. 1972 patients were assessed. 43.9% and 25.5% were admitted in General and Orthopaedic surgery services respectively. 52.8% of patients were over 60 years oíd. 31.2% did not present any concomitant illness. 36.78% had arterial hypertension and 16.5% diabetes mellitus. Pain scales to measure pain intensity, were used by 5.8% of patients at admission. In the following visits, these percentages ranged from 10% to 15%. During postoperative period NSAIDs were the most widely used (specially metamizol, administrated from 63.6% to 40.5% of the patients) and acetaminophen which was used by 41.3% of the patients in the first 12 hours and 27% in the 4th day. The percentage of patients that received rescue medication decreases from 25.7 % at first control to 6% at 4th day control; being acetaminophen the most commonly used medication. Conclusions. Despite pain treatment is considered important in surgical environments, treatment protocols are seldom used. The elaboration and the use of therapeutics guidelines for perioperative pain treatment could improve the patient comfort and their recuperation (AU)

[Late ischemic stricture following anterior rectal resection]. / Estenosis isquémica tardía tras resección anterior de recto.

A considerable incidence of colonic strictures after oncologic low anterior resections has been reported. The present paper describes a colonic stricture 5 years after the surgery, and not related to radiotherapy, that required a challenging differential diagnosis with local recurrence of rectal cancer. The role of endoscopy in the management of this condition is discussed.

Estenosis isquémica tardía tras resección anterior de recto / No disponible

Existe una incidencia no despreciable de lesiones de colon deorigen isquémico tras resecciones anteriores bajas por cáncer.Presentamos un caso de estenosis isquémica de colon, no relacionadacon radioterapia, a los 5 años de la cirugía. Se discute la dificultaddel diagnóstico diferencial con recidiva tumoral, así como elimportante papel que desempeña la endoscopia en el abordaje deestos pacientes

A considerable incidence of colonic strictures after oncologiclow anterior resections has been reported. The present paper describesa colonic stricture 5 years after the surgery, and not relatedto radiotherapy, that required a challenging differential diagnosiswith local recurrence of rectal cancer. The role of endoscopyin the management of this condition is discussed

Perianal metastases from lobular breast carcinoma.

Breast cancer gastrointestinal and soft tissue metastases are extremely rare. We present the case of a woman with perianal metastases from a primary lobular breast carcinoma 11 years after mastectomy and local radiotherapy.

Optimal dosing of bemiparin as prophylaxis against venous thromboembolism in surgery for cancer: an audit of practice.

AIMS: Low-molecular-weight heparins are drugs of first choice for thromboprophylaxis in cancer surgery. We sought to determine the optimal use of bemiparin in cancer surgery in standard clinical practice. PATIENTS AND METHODS: A retrospective, multicentre audit on the use of bemiparin in patients undergoing cancer surgery and given prophylaxis with bemiparin was undertaken. Surgeons' assessment of venous thromboembolic (VTE) risk (moderate or high) was compared to the criteria of current Consensus Guidelines for VTE management. We assessed the incidence of documented symptomatic VTE, bleeding events, thrombocytopenia, deaths and total events related to VTE or bemiparin prophylaxis (i.e. bleeding, thrombocytopenia). The potential economic impact of postoperative vs. preoperative bemiparin was also analysed. RESULTS: Clinical records from 197 patients from 5 Spanish centres were checked. Prophylaxis was started postoperatively in 45 patients (22.8%). According to the surgeons' criteria, 73 (37.1%) patients were at high VTE risk and received bemiparin 3500 IU/d. However, according to the criteria of current Guidelines, 189 (95.9%) patients were at high risk of VTE (heterogeneity P-value<0.0001). Three (1.5%) patients, all of them receiving bemiparin 2500 IU/d, developed a symptomatic confirmed VTE. There were 4 major and 5 minor bleeding events during bemiparin prophylaxis. A lower incidence of bleeding (2.2% vs. 5.3%; P=0.48) and total events (2.2% vs. 9.9%; P=0.11) was seen with bemiparin started postoperatively as compared to preoperative bemiparin. Bleeding rates did not significantly differ between patients given low or high bemiparin prophylactic doses (4.0% vs. 5.5%; P=0.72). Two patients died due to cardio-respiratory failure and sepsis, respectively. Postoperative bemiparin provided net cost savings of 909 euro per patient compared to preoperative start of prophylaxis due to shorter hospital stays (9 vs. 11 days) and lower incidence of complications in the postoperative bemiparin group. CONCLUSIONS: Many cancer patients are still poorly assessed for risk of VTE. Bemiparin 3500 IU/d is associated with a lower incidence of VTE without significant increase in complications as compared with bemiparin 2500 IU/d. Postoperative bemiparin prophylaxis seems to be as effective and safer than preoperative start of prophylaxis. Further prospective clinical studies are needed to fully address this issue.

Efficacy of albendazole against Anisakis simplex larvae in vitro.

BACKGROUND: The growing popularity in western countries of eating uncooked seafood has resulted in an increased incidence of anisakidosis. AIM: To study the in vitro activity of different concentrations of albendazole against Anisakis simplex larvae under different media pH. METHODS: A. simplex larvae were obtained from fresh hakes acquired from the fish market of Madrid. They were divided into groups and placed in culture dishes (15 larvae each) containing RPMI-1640, in the presence or absence of different concentrations of albendazole (300, 400 and 500 microg/mL). RESULTS: Albendazole dose-dependently reduced the survival of the larvae, its maximum activity being at 500 microg/mL when it killed almost all larvae at 48 h. Acidic medium pH significantly reduced the efficacy of albendazole. CONCLUSION: Albendazole is effective in killing A. simplex larvae at different pH in vitro, suggesting that this molecule could be useful in treating clinical manifestations of human anisakidosis.

Overexpression of c-myc and loss of heterozygosity on 2p, 3p, 5q, 17p and 18q in sporadic colorectal carcinoma.

AIM: The aim of the present study is to evaluate the prognostic influence of loss of heterozygosity on 2p, 3p, 5q, 17p and 18q, and c-myc overexpression on surgically treated sporadic colorectal carcinoma. METHODS: Tumor and non-tumor tissue samples from 153 patients were analyzed. Fifty-one percent of patients were male, and mean age in the series was 67 years. Tumors were located in the proximal colon in 37 cases, in the distal bowel in 37, and in the rectum in 79 patients. c-myc overexpression was studied by means of Northern blot analysis, and loss of heterozygosity through microsatellite analysis. RESULTS: c-myc overexpression was detected in 25% of cases, and loss of heterozygosity in at least one of the studied regions in 48%. There was no association between clinical and pathologic features, and genetic alterations. The disease-free interval was significantly shorter for patients with both genetic alterations; the presence of both events was an independent prognostic factor for poor outcome in the multivariate analysis (RR: 4.34, p < 0.0001). CONCLUSIONS: The presence of both loss of heterozygosity and overexpression of the c-myc oncogene separates a subset of colorectal carcinoma patients who have a shorter disease-free interval after curative-intent surgery.

Sobreexpresión de c-myc y pérdida de heterozigosidad en 2p, 3p, 5q, 17p y 18q en carcinoma colorrectal esporádico / Overexpression of c-myc and loss of heterozigosity on 2p, 3p, 5q, 17p and 18q in sporadic colorectal carcinoma

Objetivo: el objetivo del presente trabajo es evaluar la importanciapronóstica de la pérdida de heterozigosidad en las regiones2p, 3p, 5q, 17p y 18q y de la sobreexpresión del genc-myc en el carcinoma colorrectal esporádico, mediante el estudiode la supervivencia libre de enfermedad tras cirugía potencialmentecurativa.Métodos: se han analizado muestras tumorales y no tumoralesde mucosa colónica de 153 pacientes. El 51% de los pacienteseran varones y la edad media de la serie fue 67 años. Los tumoresfueron proximales en 37 casos, distales en 37 y localizados enrecto en 79. Se analizó la sobreexpresión del RNA de c-myc porNorthern blot, y la presencia de pérdida de heterozigosidad en lasdiferentes regiones consideradas por análisis de microsatélites.Resultados: se detectó sobreexpresión de c-myc en el 25%de los casos, y pérdida de heterozigosidad en alguna de las regionesestudiadas en el 48%. No hubo asociación entre las variablesclínicas o patológicas y las alteraciones génicas. Se encontró unintervalo libre de enfermedad más corto para los pacientes conpérdida de heterozigosidad y sobreexpresión de c-myc, y este factortuvo valor pronóstico independiente en el análisis multivariante(RR: 4.34, p < 0,0001).Conclusiones: la coexistencia de pérdida de heterozigosidady sobreexpresión del oncogén c-myc distingue un grupo de pacientescon recurrencia más precoz tras cirugía curativa por carcinomacolorrectal

Aim: the aim of the present study is to evaluate the prognosticinfluence of loss of heterozygosity on 2p, 3p, 5q, 17p and 18q,and c-myc overexpression on surgically treated sporadic colorectalcarcinoma.Methods: tumor and non-tumor tissue samples from 153 patientswere analyzed. Fifty-one percent of patients were male, andmean age in the series was 67 years. Tumors were located in theproximal colon in 37 cases, in the distal bowel in 37, and in therectum in 79 patients. c-myc overexpression was studied bymeans of Northern blot analysis, and loss of heterozigositythrough microsatellite analysis.Results: c-myc overexpression was detected in 25% of cases,and loss of heterozygosity in at least one of the studied regionsin 48%. There was no association between clinical andpathologic features, and genetic alterations. The disease-freeinterval was significantly shorter for patients with both geneticalterations; the presence of both events was an independentprognostic factor for poor outcome in the multivariate analysis(RR: 4.34, p < 0.0001).Conclusions: the presence of both loss of heterozygosity andoverexpression of the c-myc oncogene separates a subset of colorectalcarcinoma patients who have a shorter disease-free intervalafter curative-intent surgery

Clinical relevance of MMP-9, MMP-2, TIMP-1 and TIMP-2 in colorectal cancer.

The main aim of this study was to evaluate the clinical relevance of Gelatinases in colorectal cancer (CRC). Ninety-five CRCs and their paired normal tissues were investigated to detect total levels of MMP-9, MMP-2, and the tissue inhibitors TIMP-1 and TIMP-2. Also, pro-MMP and MMP activity, and potential associations with clinical parameters were estimated. MMP-9, MMP-2 and TIMP-1 levels were greater in CRCs than in normal tissues, differences being significant for MMP-9 and TIMP-1. However, TIMP-2 showed significantly lower levels in tumour samples. Moreover, significant differences in the state of activation between gelatinases were found. TIMP-1 low levels were significantly associated with poor clinical outcome of patients. According to these data, different roles have to be attributed to MMP-2 and MMP-9 in CRC progression. Moreover, TIMP-1 level evaluation emerges as the main prognostic factor in relation to Gelatinases A and B activity in CRC.

Non-heart-beating donation: current state of the art.

The use of non-heart-beating donors (NHBD) helps us to deal with the problem of the organ shortage. In addition to difficulties with legal and ethical acceptability, there are concerns regarding medical safety, which prevent the widespread use of these donors. To make optimum use of this potential organ supply, the ischemic injury that occurs after a period of warm ischemia needs to be reversed. To minimize the warm ischemia time, once the subject is declared dead, most centers commence in situ cold perfusion via a femoral access or a rapid aortic cannulation. This usually occurs within minutes of arriving at the emergency department, before the next of kin have been notified of the patient's death. The European experience of kidney transplantation from NHBD shows promising results. The long-term outcomes are similar to HBD kidneys notwithstanding a higher rate of delayed graft function, which seems not to affect the long-term survival of these kidneys. In summary, NHBD may have an important impact on the large discrepancy that exists between the organ supply and the demand. Current data suggest that the results may be further improved by better patient selection and retrieval team organization.

Prognostic significance of the p185 protein in colorectal cancer.

The amplification and/or overexpression of the c-erbB-2/neu oncogene may play a role in tumor development and progression. The aim of this prospective study was to evaluate the prognostic value of p185 protein in colorectal cancer using immunohistochemical techniques. We analyzed 106 colorectal tumor tissue specimens from patients who had been operated on by the same surgeon and subjected to a median follow-up of 3 years. Thirty-three per cent of patients showed p185 overexpression related to an advanced stage of the disease. In patients with adenocarcinoma tumors of the colon without distant metastases, p185 detection was found to be of clinical prognostic relevance (p = 0.06).

Relationship between 3p deletions and telomerase activity in non-small-cell lung cancer: prognostic implications.

3p deletions and telomerase reactivation are two of the most frequent events described in relation to non-small-cell lung cancer (NSCLC) pathogenesis. Moreover, a number of genes that map on 3p have been proposed as candidates to tumour-suppressor genes of importance in the lung cancer process. In this work, we analysed deletions at different 3p loci in relationship to telomerase activity in 66 NSCLCs obtained from patients who had suffered potentially curative surgery. Also, we evaluated prognostic implications. DNA samples were analysed for 3p deletions using five different polymorphic human dinucleotide repeat DNA markers (D3S1619 at 3p22.2, D3S3623 at 3p22.1, D3S1260 at 3p21.33, D3S3697 at 3p14.3, and D3S3722 at 3p21.2). Telomerase activity was investigated by a TRAP-based method. Possible correlations between the different molecular markers and distributions of disease-free survival were estimated. Our data revealed a significant correlation between telomerase activity and losses of heterozygosity (LOH) on D3S3697 (P=0.040), since all of the tumours showing deletion at this locus were positives for telomerase. Moreover, our results revealed clear associations with poor prognosis of patients, in the case of LOH at D3S1260 and D3S3697 (P=0.005 and 0.005, respectively). According to our data, potential repressors for telomerase may be located in chromosome 3p.

Modificación de los mediadores inflamatorios en isquemia-reperfusión intestinal en un modelo de diabetes tipo 2 / Modification of inflammatory mediators in intestinal ischemia-reperfusion in a model of type II diabetes

Introducción. Se ha demostrado que los polimorfonucleares aislados de pacientes diabéticos presentan un mayor grado de activación que los de los pacientes no diabéticos. Además, la diabetes, tanto de tipo 1 como de tipo 2, se asocia con un incremento de la peroxidación lipídica y valores elevados de moléculas de adhesión circulantes. La administración de estreptozotocina (STZ) en ratas neonatales conduce en las ratas adultas a una ligera deficiencia de insulina, con valores de glucemia normales, y son aceptadas como modelo de diabetes tipo 2.Objetivo. En este estudio hemos investigado posibles diferencias en plasma y tejidos de algunos mediadores de la inflamación entre ratas normales y ratas con diabetes tipo 2, después de isquemiareperfusión (I-R) intestinal. Material y métodos. Se utilizaron ratas Wistar a las que se les administró STZ (0 o 30 mg/kg) el día de su nacimiento. Dos meses después, tanto las ratas control como las que tenían diabetes tipo 2 (normoglucémicas) fueron asignadas aleatoriamente a dos grupos. El grupo I fue sometido a un período de 60 min de isquemia intestinal por pinzamiento de la arteria mesentérica superior. Cinco minutos después de la reperfusión, las ratas fueron sacrificadas y se obtuvieron muestras de vena porta (VP), cava infrahepática (CIH), cava suprahepática (CSH), páncreas e intestino. En el grupo control los animales se manipularon de igual forma, pero sin ser sometidos a IR. El óxido nítrico (NO) se midió como NO-2 + NO-3, por la reacción de Griess. Los hidroperóxidos lipídicos (LPO) fueron determinados espectrofotométricamente usando un kit comercial. Los receptores para factor de necrosis tumoral (TNF) de 60 kDa (TNF-R1) y 75 kDa (TNF-R2), y el ICAM-1 se determinaron por el método Elisa. Resultados. Tras la I-R, las ratas diabéticas evidenciaron un aumento de las concentraciones plasmáticas de LPO, NO, ICAM-1 (0,514 + 0,083 frente a 0,046 + 0,011 CIH; 0,574 + 0,075 frente a 0,037 + 0,009 CSH, y 0,528 + 0,067 frente a 0,033 + 0,009 VP; ng/ml; n = 10; p < 0,01), TNF (42,4 + 5,7 CIH, 248,4 + 28,2 CSH y 33,6 + 4,0 VP, pg/ml, en ratas diabéticas frente a no detectable en ratas control; n = 10), TNF-R1 (0,179 + 0,024 frente a 0,023 + 0,011 CIH; 0,233 + 0,032 frente a 0,033 + 0,005 CSH; 0,206 + 0,034 frente a 0,039 + 0,023 VP; ng/ml; n = 10; p < 0,001; p < 0,05 todas) mientras que no se encontraron diferencias en los valores de TNF-R2 entre ambos grupos. Tras I-R, los valores plasmáticos de TNF y NO fueron más elevados en CSH que en CIH y VP, lo que sugiere que el hígado es una importante fuente de ambos mediadores. Hemos observado que tras I-R en ratas diabéticas en el tejido intestinal se produce un aumento en los valores de TNF, interleucina (IL) 1, IL-6 (no significativo) e IL-10, mientras que en el tejido pancreático hay una disminución de TNF- e IL-10 y un aumento de IL-1 e IL-6.Conclusión. La diabetes tipo 2 intensifica la respuesta inflamatoria a la I-R intestinal (AU)

Metilación del gen p16 en el carcinoma broncogénico no microcítico. Implicación pronóstica / Methylation of gene p16 in non-small cell bronchogenic carcinoma. Prognostic implication

La importancia sociosanitaria del cáncer de pulmón radica en su elevada incidencia y mortalidad. En la actualidad se considera el cáncer como el resultado de una acumulación de alteraciones genéticas que afectan a diversos genes con distintas funciones celulares. Los estudios genéticos han demostrado alteraciones en la región 21 del brazo corto del cromosoma 9 (9p21), que son frecuentemente identificadas en el cáncer humano. Esta región contiene un gen supresor llamado p16, que codifica las proteínas p16 y p19. Se ha observado que, aunque la pérdida de heterocigosidad (LOH) es un mecanismo frecuente de inactivación del gen, la metilación del promotor de p16 también es una alteración importante que suprime la función del gen. Se estudió una serie de 98 pacientes diagnosticados de carcinoma de pulmón no microcítico. Se analizó la LOH en 9p21 mediante el análisis de polimorfismos de microsatélites y el estado de metilación del gen p16. El 23,5 per cent de los pacientes presentaban LOH y/o inestabilidad en 9p21 y el 54,5 per cent metilación de p16. Los pacientes que no presentaban alteraciones genéticas en p16 tenían un riesgo relativo de fallecer 1,67 veces mayor (p = 0,1) que los que sí presentaban alguna de estas alteraciones (AU)

3p21, 5q21, and 9p21 allelic deletions are frequently found in normal bronchial cells adjacent to non-small-cell lung cancer, while they are unusual in patients with no evidence of malignancy.

Molecular cytogenetic and loss of heterozygosity (LOH) analyses of non-small-cell lung cancer (NSCLC) have shown frequent allelic deletions in a variety of chromosomes, such as 1p, 3p, 5q, 8p, 9p, 11p, 11q, and 17p. Allelic loss at 3p21, 9p21, and 5q21 has also been reported in premalignant epithelial lesions of the bronchus and in normal bronchial cells. These findings suggest that a tissue field of somatic genetic alterations precedes the histopathological phenotypic changes of carcinoma. LOH at chromosomal regions 3p21, 5q21, 9p21, and 17p (TP53) was looked for in the peritumoural normal bronchial cells from 30 archival surgically resected tumours. Microdissected normal bronchial cells from 20 benign cytological smears were also added to the study. Matched populations of lymphocytes, tumour cells, and normal bronchial cells adjacent to the tumour were microdissected from paraffin-embedded tissues, while matched populations of normal bronchial cells and inflammatory cells were microdissected from benign cytological smears (bronchial brushings). Polymerase chain reaction (PCR) amplification was performed utilizing the specific markers D5S346, D3S1300, D9S157, D9S171, and TP53. Within the NSCLC tumour cells, LOH was more frequently found at the 5q21 locus (72% of the informative cases), the 3p21 locus (47%), 9p21 (48%), and 17p (33%). Within the peritumoural normal bronchial cells, LOH at 5q21 was found in 37.5% of the cases, 22% showed LOH at 3p21, 27% at 9p21, and 13% at 17p (TP53). LOH was also detected in one case, in normal bronchial cells obtained from cytological smears at one locus (5q21). In conclusion, normal bronchial mucosa adjacent to NSCLC has frequent allelic losses at 3p21, 5q21, and 9p21, while LOH at these loci is unusual in normal bronchial cells obtained from cytological smears from patients with no evidence of malignancy. LOH at these loci may be present before the onset of the malignant growth. LOH studies may supplement the histopathological evaluation of bronchial cells to detect genotypic alterations in both cytological and biopsy specimens.

Últimos avances en el campo del trasplante de islotes de Langerhans / Update in clinical islet transplantation

Las complicaciones tardías de la diabetes constituyen un importante problema de salud pública y hoy día está demostrado que se deben a que el tratamiento habitual con insulina inyectada proporciona un control inadecuado de la glucemia. En pacientes con diabetes tipo I, se puede conseguir un buen control glucémico mediante la terapia intensiva con insulina o mediante un trasplante de páncreas. La terapia intensiva con insulina no logra normalizar las cifras de hemoglobina glucosilada y presenta un riesgo considerable de crisis de hipoglucemia. El trasplante de páncreas proporciona un control metabólico excelente y, aunque sus resultados han mejorado espectacularmente durante la última década, continúa siendo un procedimiento invasivo y con una morbilidad significativa. El trasplante de islotes aislados representa la alternativa más lógica para el tratamiento de estos pacientes. En un estudio reciente, que utiliza un innovador régimen inmunosupresor, el trasplante de islotes se acompañó de una morbilidad irrelevante y logró en todos los pacientes un buen control metabólico con normalización de la hemoglobina glucosilada e independencia de la insulina mantenidas (AU)

Utilización de índices de gravedad en la sepsis / Use of disease severity scoring indexes in sepsis

Las escalas de puntuación de gravedad intentan integrar datos clínicos en una única variable numérica con capacidad para predecir el curso de un paciente. El beneficio indirecto de dichas escalas es ampliamente aceptado. En primer lugar, cuando estos sistemas se aplican en la investigación, los resultados pueden ser comparados más fácilmente y los ensayos clínicos son más objetivos y reproducibles. En segundo lugar, las puntuaciones pueden utilizarse en la evaluación de la calidad y las comparaciones de la mortalidad esperada y observada pueden ser usadas para evaluar la eficacia de la UCI. En tercer lugar, la puntuación de la gravedad de los cuadros en los pacientes de la UCI pueden ayudar a economistas y administradores en decisiones presupuestarias. En cuarto lugar, trabajar con sistemas de puntuación tiene un efecto formativo y puede ayudar a suplir la falta de experiencia en facultativos jóvenes. Se considera que existe un efecto directo cuando, en base a una puntuación, se inician, retiran o deniegan procedimientos diagnósticos o terapéuticos. Es necesario enfatizar que los indicadores pronósticos reflejan la evolución esperada para un grupo de pacientes, y su utilidad para tomar decisiones en relación con la atención a un paciente individual es muy limitada. Un sistema predictivo estadístico no debería nunca liberar al médico de su deber de tener en cuenta al paciente en conjunto para sus decisiones. El pronóstico basado en escalas de puntuación sigue, por tanto, suponiendo sólo una pequeña porción del complejo puzzle que es el proceso de decisión del médico (AU)

Valor pronóstico de la pérdida de heterozigosidad en la región 9p21 en el carcinoma broncogénico no microcítico / Prognostic value of loss of heterozygosity at chromosome 9p21 in nonsmall cell bronchogenic carcinoma

La importancia sociosanitaria del cáncer de pulmón radica en su elevada incidencia y mortalidad. En la actualidad se considera el cáncer como el resultado de una acumulación de alteraciones que afectan a diversos genes con distintas funciones celulares. Diversos estudios genéticos han demostrado una pérdida de material genético en la región 21 del brazo corto del cromosoma 9 (9p21), siendo una de las alteraciones genéticas más frecuentemente identificadas en el cáncer humano. Esta región contiene un gen supresor llamado p16, que codifica las proteínas p16 y p19.Se estudió una serie de 98 pacientes diagnosticados de carcinoma de pulmón no microcítico. Se analizó la pérdida de heterozigosidad (LOH) en 9p21 mediante el análisis de polimorfismos de microsatélites. El 23,5 por ciento de los pacientes presentaba LOH y/o inestabilidad en 9p21. Contrariamente a lo que se esperaba, los pacientes que no presentaban alteraciones genéticas en p16 tenían un riesgo relativo de fallecer 1,7 veces mayor (p = 0,1) que los que sí presentaban LOH y/o inestabilidad (AU)