Guía de práctica clínica para la elección del fluido de restauración volémica perioperatoria en los pacientes adultos intervenidos de cirugía no cardiaca / Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery

Esta Guía de Práctica Clínica responde a preguntas clínicas sobre seguridad en la elección de fluido (cristaloide, coloide o Hidroxietilalmidón 130) en pacientes que precisan restauración volémica en el periodo perioperatorio de cirugía no cardiaca. A partir del resumen de la evidencia, se elaboraron las recomendaciones siguiendo la metodología GRADE. En esta población se sugiere la fluidoterapia basada en la administración de cristaloides, (recomendación débil, calidad de la evidencia baja). En las situaciones en las que la restauración volémica no se alcance sólo con cristaloides, se sugiere utilizar coloides sintéticos (Hidroxietilalmidón 130 o gelatina fluida modificada) en lugar de Albúmina 5% (recomendación débil, calidad de la evidencia baja). La elección y dosificación de coloide deberán basarse en las características del producto, comorbilidad del paciente y experiencia del anestesiólogo (AU)

The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience (AU)

Clinical practice guide for the choice of perioperative volume-restoring fluid in adult patients undergoing non-cardiac surgery.

The present Clinical practice guide responds to the clinical questions about security in the choice of fluid (crystalloid, colloid or hydroxyethyl starch 130) in patients who require volume replacement during perioperative period of non-cardiac surgeries. From the evidence summary, recommendations were made following the GRADE methodology. In this population fluid therapy based on crystalloids is suggested (weak recommendation, low quality evidence). In the events where volume replacement is not reached with crystalloids, the use of synthetic colloids (hydroxyethyl starch 130 or modified fluid gelatin) is suggested instead of 5% albumin (weak recommendation, low quality evidence). The choice and dosage of the colloid should be based in the product characteristics, patient comorbidity and anesthesiologist's experience.

Fluidoterapia en cirugía cardiaca. Puesta al día / Fluid therapy in cardiac surgery. An update

En la cirugía cardiaca, el anestesiólogo dispone de 2 grandes herramientas para la optimización hemodinámica: los fármacos vasoactivos y el volumen intravascular. Es vital identificar qué pacientes se beneficiarán de una u otra terapia para una adecuada respuesta al tratamiento. La monitorización hemodinámica con los distintos parámetros existentes (presión, volumétricos estáticos, volumétricos funcionales y ecocardiográficos) permite optimizar el tratamiento de estos pacientes. Resumimos en este artículo las publicaciones más recientes y relevantes y las distintas herramientas disponibles para guiar la fluidoterapia en este contexto con el fin de sugerir pautas de monitorización hemodinámica en los pacientes sometidos a cirugía cardiaca. Se ha realizado una búsqueda sistemática en PubMed, limitando los resultados a las publicaciones de los últimos 5 años, hasta febrero de 2012 (AU)

The anesthetist has 2 major tools for optimizing haemodynamics in cardiac surgery: Vasoactive drugs and the intravascular volume. It is necessary to identify which patients would benefit from one or the other therapies for a suitable response to treatment. Hemodynamic monitoring with the different existing parameters (pressure, volumetric static, volumetric functional and echocardiography) allows the management of these patients to be optimized. In this article a review is presented on the most recent and relevant publications, and the different tools available to control the management of the fluid therapy in this context, and to suggest a few guidelines for the haemodynamics monitoring of patients submitted to cardiac surgery. A systematic search has been made in PubMed, limiting the results to the publications over the last five years up to February 2012 (AU)

[Fluid therapy in cardiac surgery. An update]. / Fluidoterapia en cirugía cardiaca. Puesta al día.

The anesthetist has 2 major tools for optimizing haemodynamics in cardiac surgery: Vasoactive drugs and the intravascular volume. It is necessary to identify which patients would benefit from one or the other therapies for a suitable response to treatment. Hemodynamic monitoring with the different existing parameters (pressure, volumetric static, volumetric functional and echocardiography) allows the management of these patients to be optimized. In this article a review is presented on the most recent and relevant publications, and the different tools available to control the management of the fluid therapy in this context, and to suggest a few guidelines for the haemodynamics monitoring of patients submitted to cardiac surgery. A systematic search has been made in PubMed, limiting the results to the publications over the last five years up to February 2012.

The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis).

Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment).

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

The cytotoxicity of eosinophil cationic protein/ribonuclease 3 on eukaryotic cell lines takes place through its aggregation on the cell membrane.

Human eosinophil cationic protein (ECP)/ ribonuclease 3 (RNase 3) is a protein secreted from the secondary granules of activated eosinophils. Specific properties of ECP contribute to its cytotoxic activities associated with defense mechanisms. In this work the ECP cytotoxic activity on eukaryotic cell lines is analyzed. The ECP effects begin with its binding and aggregation to the cell surface, altering the cell membrane permeability and modifying the cell ionic equilibrium. No internalization of the protein is observed. These signals induce cell-specific morphological and biochemical changes such as chromatin condensation, reversion of membrane asymmetry, reactive oxygen species production and activation of caspase-3-like activity and, eventually, cell death. However, the ribonuclease activity component of ECP is not involved in this process as no RNA degradation is observed. In summary, the cytotoxic effect of ECP is attained through a mechanism different from that of other cytotoxic RNases and may be related with the ECP accumulation associated with the inflammatory processes, in which eosinophils are present.

An isolated pituitary metastasis as presentation of a differentiated hepatocellular carcinoma mimicking a nonfunctioning macroadenoma.

The differential diagnosis of sellar masses may be complex. Metastatic disease constitutes 1% of all pituitary lesions and sometimes mimics the clinical-radiological presentation of pituitary adenoma. The definitive diagnosis usually relies on histology, but occasionally even histological features of pituitary metastasis may resemble those of adenomas. We present a patient initially diagnosed with pituitary adenoma, but whose clinical course finally revealed pituitary metastasis of a hepatocellular carcinoma. The existing literature on this topic is reviewed.

Outcome of pregnancy in a hypothyroid woman with resistance to thyroid hormone treated with triiodothyronine.

Epidemiological and research data have shown the significant role of maternal thyroid hormone in fetal neurologic development. It has been suggested that maternal hypothyroxinemia is potentially damaging for the neurodevelopment of the fetus, independently of T3 levels. We present a pregnant woman with resistance to thyroid hormone and iatrogenic hypothyroidism who was treated with triiodothyronine during the whole pregnancy. Even though maternal hypothyroxinemia was severe the children showed a normal neuropsychological development.

Comparison of two low-calorie diets: a prospective study of effectiveness and safety.

OBJECTIVE: To evaluate the cost-effectiveness and safety of two distinct low calorie diets (LCD). DESIGN: Prospective controlled study. METHODS: 67 obese patients [body mass index (BMI) 40 kg/m2] were included in two study groups. Group A: 26 patients followed a 458 kcal diet given in three meals for 1 month. Group B: 41 patients followed a 800 kcal diet for 3 months and with outpatient control. MEASUREMENTS: Anthropometric, cardiovascular risk and nutritional profile changes were evaluated, as well as total direct and indirect costs, and the incidence of complications. RESULTS: No significant initial differences were observed between the two study groups. Eighty-six point two per cent of the patients completed the therapy correctly. After treatment a significant decrease was observed in the following variables for both groups, but no differences were detected between Groups A and B: mean weight loss (A= 9.28 kg, B= 8.7 kg), ponderal loss percentage (A/B= 7.2/6.8%), glycemia (A/B= 18.6/12.1 mg/dl), systolic blood pressure (SBP) (A/B= 11.8/6.5 mmHg), diastolic blood pressure (DBP) (A/B 5.9/6.8 mmHg), and final insulin-resistance (IR) index (A= 4.4, B= 4.3). Group A had the highest drop in total cholesterol (37.7 vs 8.1 mg/dl) and triglycerides (54.4 vs 2.5 mg/dl). No changes were observed in ureic acid, renal function and serum albumin. Thirty-six patients (55.3%) suffered trivial complications associated to the VLCD (16.9% gastrointestinal, 20% anxiety), with no differences between groups. Group A patients were on sick leave due to asthenia, and two patients in this group had serious complications (transient ischemic attack and atrial fibrillation). The total cost of Group A treatment was 3018.9 against 582.6 euros for Group B. CONCLUSIONS: The 3-month 800 kcal/day VLCD was more cost-effective and safer than the 1-month 458 kcal/day diet.

Insuficiencia suprarrenal por mutación del gen StAR / Adrenal insufficiency due to a mutation in the StAR gene

El seudohermafroditismo masculino (SHM) es una entidad heterogénea con un abordaje diagnóstico complejo, dado el amplio espectro clínico y las numerosas etiologías potencialmente causantes. La mutación del gen codificador de la proteína de la regulación aguda de la esteroidogénesis (StAR) causa la hiperplasia suprarrenal congénita lipoidea (HSCL), una entidad muy infrecuente caracterizada por una ausencia de esteroidogénesis adrenal y gonadal, resultando en una insuficiencia adrenal grave y un SHM. Se presenta a un paciente 46,XY de 29 años de edad, fenotípicamente mujer, referido para control de una afección adrenal no diagnosticada. Los esteroides plasmáticos adrenales y gonadales eran indetectables, con una elevación franca de las gonadotrofinas. El estudio del gen StAR mostró una mutación heterocigota en el exón 3 (CTn327-328) y una mutación homocigota en el exón 7 (L275P), confirmando el diagnóstico de HSCL (AU)

Male pseudohermaphroditism is a heterogeneous condition. Diagnosis is complex because of its phenotypic variability and the large number of potential causes. A mutation in the steroidogenic acute regulatory protein (StAR) gene causes congenital lipoid adrenal hyperplasia (CLAH), characterized by the absence of adrenal and gonadal steroidogenesis, resulting in severe adrenal insufficiency and male pseudohermaphroditism. We report the case of a 27-year-old, 46,XY phenotypic woman, who was referred because of an undiagnosed adrenal disease. Basal adrenal and gonadal plasma steroids were undetectable and there was marked elevation of gonadotrophins. Study of the StAR gene revealed a heterozygous mutation in exon 3 (CTn327-328) and a homozygous mutation in exon 7 (L275P), confirming the diagnosis of CLAH (AU)

[Prognostic morbidity and mortality factors in hospital enteral nutrition: prospective study]. / Factores pronósticos de morbi-mortalidad en nutrición enteral hospitalaria: estudio prospectivo.

OBJECTIVE: To determine the prognostic factors that may best for see the outcome of an enteral nutritional intervention and to assess the assistance quality of a nutrition unit. SETTING AND SUBJECTS: Patients that required enteral nutrition during hospital admission at a third level center. INTERVENTIONS: Observational prospective study in which 160 patients were included by means of consecutive sampling, for a 6-months follow-up period. Underlying pathology, disability degree, nutritional assessment, type of enteral nutrition, complications, nursing care, and clinical course of patients were determined. RESULTS: severe caloric and protein hyponutrition was diagnosed in 48.4 and 52.9% of patients; stress degree was moderate in 52.2% and severe in 36.5%. In 88.2% of patients variation of protein parameters was unchanged or improved, with a 0.26 g/dL increase in albumin levels and 2.4 m/dL in prealbumin (p < 0.05). Multivariate analysis adjusted for plasma albumin at admission showed that besides this biochemical parameter, a severe stress degree, a decreased alertness level, and worsening of protein variation during admission are independent prognostic mortality factors during an enteral nutritional intervention in the hospitalized patient (p < 0.05). CONCLUSIONS: alertness level, degree of caloric hyponutrition, stress degree, plasma albumin levels, and variation of protein parameters during nutritional support are independent prognostic factors for the nutritional intervention outcomes. The development of global monitoring systems of assistance activity and quality of Nutrition Units is paramount in order to improve the efficiency of enteral nutritional support at the hospital setting, to advance in patients care and promote the development of nutritional therapy.

Factores pronósticos de morbi-mortalidad en nutrición enteral hospitalaria: estudio prospectivo / Prognostic morbidity and mortality factors in hospital enteral nutrition: prospective study

Objetivos: Determinar aquellos factores pronósticos que mejor puedan prever el resultado de una intervención nutricional vía enteral y evaluar la calidad asistencial de una unidad de nutrición. Ámbito y sujetos: Pacientes que precisaron nutrición enteral en régimen de ingreso hospitalario, en un centro de 3.er nivel. Intervenciones: Estudio observacional, prospectivo, en el que se incluyeron 160 pacientes mediante muestreo consecutivo, durante un período de seguimiento de 6 meses. Se determinó: patología de base, grado de incapacidad, valoración nutricional, tipo de nutrición enteral, complicaciones, cuidados de enfermería y evolución clínica de los pacientes. Resultados: Se diagnosticó desnutrición calórica y protéica graves en el 48,4 y 52,9% de los pacientes; el grado de estrés fue moderado en el 52,2% y grave en el 36,5%. En el 88,2% de los pacientes la variación de los parámetros protéicos fueron de igual o mejor, con un incremento en las concentraciones de albúmina de 0,26 g/dl y prealbúmina de 2,4 mg/dl (p < 0,05). El análisis multivariante, ajustado por la albúmina plasmática al ingreso mostró que, además de este parámetro bioquímico, el grado de estrés grave, el nivel de consciencia disminuido, y el empeoramiento en la variación protéica durante el ingreso, son factores pronósticos independientes de mortalidad en el transcurso de una intervención nutricional enteral en el paciente hospitalizado (p < 0,05). Conclusiones: El nivel de consciencia, grado de desnutrición calórica, grado de estrés, concentraciones de albúmina plasmática y la variación de los parámetros proteicos durante el soporte nutricional, son factores pronósticos independientes del resultado de una inter-vención nutricional. El desarrollo de sistemas de monitorización global de la actividad y calidad asistencial de las Unidades de Nutrición, son básicos para mejorar la eficiencia del soporte nutricional vía enteral en el ámbito intrahospitalario, avanzar en el cuidado de los pacientes y favorecer el desarrollo de la terapia nutricional (AU)

Objective: To determine the prognostic factors that may best for see the outcome of an enteral nutritional intervention and to assess the assistance quality of a nutrition unit. Setting and subjects: Patients that required enteral nutrition during hospital admission at a third level center. Interventions: observational prospective study in which 160 patients were included by means of consecutive sampling, for a 6-months follow-up period. Underlying pathology, disability degree, nutritional assessment, type of enteral nutrition, complications, nursing care, and clinical course of patients were determined. Results: severe caloric and protein hyponutrition was diagnosed in 48.4 and 52.9% of patients; stress degree was moderate in 52.2% and severe in 36.5%. In 88.2% of patients variation of protein parameters was unchanged or improved, with a 0.26 g/dL increase in albumin levels and 2.4 m/dL in prealbumin (p < 0.05). Multivariate analysis adjusted for plasma albumin at admission showed that besides this biochemical parameter, a severe stress degree, a decreased alertness level, and worsening of protein variation during admission are independent prognostic mortality factors during an enteral nutritional intervention in the hospitalized patient (p < 0.05). Conclusions: alertness level, degree of caloric hyponutrition, stress degree, plasma albumin levels, and variation of protein parameters during nutritional support are independent prognostic factors for the nutritional intervention outcomes. The development of global monitoring systems of assistance activity and quality of Nutrition Units is paramount in order to improve the efficiency of enteral nutritional support at the hospital setting, to advance in patients care and promote the development of nutritional therapy (AU)

Inhibidores de la absorción del colesterol / Cholesterol absorption inhibitors

La hipercolesterolemia es un factor de riesgo cardiovascular. La reducción eficaz y a largo plazo de las concentraciones de colesterol total y ligado a lipoproteínas de baja densidad previene la mortalidad por enfermedad coronaria. Hasta la fecha los fármacos más eficaces para reducir las concentraciones plasmáticas de colesterol eran los inhibidores de la hidroximetilglutaril coenzima A reductasa (estatinas). Sin embargo, en muchos pacientes la monoterapia con estos fármacos no consigue la reducción del colesterol hasta las cifras establecidas por las guías de actuación clínica, por lo que se hace necesario el tratamiento combinado con otros hipolipemiantes. En el presente artículo se revisan los fármacos que actúan fundamentalmente a través de una inhibición de la absorción del colesterol y su utilidad en la práctica clínica (AU)

Hypercholesterolemia is a cardiovascular risk factor. Effective and long-term reduction of total and low-density lipoprotein cholesterol concentrations lowers mortality from coronary heart disease. Until now the most effective cholesterol-lowering drugs have been hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins). However many patients do not achieve standard treatment goals as defined by clinical guidelines with statins in monotherapy and require combination therapy with other lipid lowering drugs. The present review discusses the pharmacologic agents that act through inhibition of cholesterol absorption and their role in the clinical management of hypercholesterolemia (AU)

Teratogenicity with angiotensin II receptor antagonists in pregnancy.

Angiotensin converting enzyme (ACE) inhibitors and angiotensin II (AT-II)-receptor-antagonists have been demonstrated to cause fetotoxicity when administered to women during the second and third trimester of pregnancy. Although use of ACE inhibitors during the first trimester of pregnancy seems to be safe, with no associated teratogenicity, there is not sufficient information regarding the safety of first-trimester exposure to AT-II-receptor-antagonists. We report a case of exencephaly and unilateral renal agenesia in a fetus of a diabetic woman who became pregnant while taking irbesartan.

Tratamiento de la enfermedad de Graves-Basedow con tionamidas: una alternativa con riesgos / Thionamide treatment in Graves´ disease: an alternative with risks

Las tionamidas son fármacos muy eficaces para controlar el hipertiroidismo de la enfermedad de Graves-Basedow. Habitualmente se emplean como tratamiento de primera línea y se mantienen durante 12 a 24 meses con el objetivo de inducir una remisión de la enfermedad. En caso de recurrencia tras su suspensión, los pacientes son habitualmente tratados mediante radioyodo o cirugía, lo que supone una resolución definitiva del hipertiroidismo. Sin embargo, algunos pacientes son tratados de forma persistente con estos fármacos, bien por presentar alguna contraindicación para otras modalidades terapéuticas, o bien por la preferencia del paciente o de su médico responsable. Esta alternativa terapéutica puede asociarse a un mayor riesgo de crisis tirotóxica. Se presenta el caso de una paciente que presentó una crisis tirotóxica durante el tratamiento con metimazol (AU)

Rentabilidad de las pruebas de imagen en el diagnóstico de tumores enteropancreáticos en el síndrome MEN1. A propósito de un caso / Utility of imaging tests in the diagnosis of enteropancreatic tumors in men1 syndrome: a case report

El cuadro clínico del síndrome de la neoplasia endocrina múltiple tipo 1 comprende un amplio espectro de enfermedades, con afección de múltiples órganos endocrinos. Desde el inicio del diagnóstico genético, realizado por el estudio de leucocitos en sangre periférica, esta afección se ha podido diagnosticar de forma más precisa, con un seguimiento estrecho a muchos portadores asintomáticos de la mutación, basado en determinaciones hormonales y pruebas de imagen. En el caso presentado, se comenta el tratamiento de forma agresiva, según las técnicas de imagen, realizadas en una mujer de 26 años asintomática, portadora de la mutación del gen MEN1, con hiperparatiroidismo primario, hiperprolactinemia y tumor pancreático, con sospecha de metástasis hepática, según los hallazgos de la tomografía computarizada y la resonancia magnética, pero no en la gammagrafía. Se comentan las características del cuadro clínico, la genética, el diagnóstico y el tratamiento del síndrome de la neoplasia endocrina múltiple tipo 1, con especial énfasis en los tumores enteropancreáticos y las técnicas de imagen (AU)

Tolerabilidad y eficacia en el tratamiento a largo plazo con polímeros de análogos de somatostatina en tirotropinomas. A propósito de 2 casos / Tolerability and efficacy of long-term treatment with somatostatin analog polymers in thyrotropinoma: 2 case reports

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