The error of estimated GFR in predialysis care.

The error of estimated glomerular filtration rate (eGFR) and its consequences in predialysis are unknown. In this prospective multicentre study, 315 predialysis patients underwent measured GFR (mGFR) by the clearance of iohexol and eGFR by 52 formulas. Agreement between eGFR and mGFR was evaluated by concordance correlation coefficient (CCC), total deviation index (TDI) and coverage probability (CP). In a sub-analysis we assessed the impact of eGFR error on decision-making as (i) initiating dialysis, (ii) preparation for renal replacement therapy (RRT) and (iii) continuing clinical follow-up. For this sub-analysis, patients who started RRT due to clinical indications (uremia, fluid overload, etc.) were excluded. eGFR had scarce precision and accuracy in reflecting mGFR (average CCC 0.6, TDI 70% and cp 22%) both in creatinine- and cystatin-based formulas. Variations -larger than 10 ml/min- between mGFR and eGFR were frequent. The error of formulas would have suggested (a) premature preparation for RTT in 14% of stable patients evaluated by mGFR; (b) to continue clinical follow-up in 59% of subjects with indication for RTT preparation due to low GFRm and (c) to delay dialysis in all asymptomatic patients (n = 6) in whom RRT was indicated based on very low mGFR. The error of formulas in predialysis was frequent and large and may have consequences in clinical care.

Treatment of Chronic Heart Failure in Advanced Chronic Kidney Disease: The HAKA Multicenter Retrospective Real-World Study.

INTRODUCTION: Chronic heart failure (HF) has high rates of mortality and hospitalization in patients with advanced chronic kidney disease (aCKD). However, randomized clinical trials have systematically excluded aCKD population. We have investigated current HF therapy in patients receiving clinical care in specialized aCKD units. METHODS: The Heart And Kidney Audit (HAKA) was a cross-sectional and retrospective real-world study including outpatients with aCKD and HF from 29 Spanish centers. The objective was to evaluate how the treatment of HF in patients with aCKD complied with the recommendations of the European Society of Cardiology Guidelines for the diagnosis and treatment of HF, especially regarding the foundational drugs: renin-angiotensin system inhibitors (RASi), angiotensin receptor blocker/neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). RESULTS: Among 5,012 aCKD patients, 532 (13%) had a diagnosis of HF. Of them, 20% had reduced ejection fraction (HFrEF), 13% mildly reduced EF (HFmrEF), and 67% preserved EF (HFpEF). Only 9.3% of patients with HFrEF were receiving quadruple therapy with RASi/ARNI, BB, MRA, and SGLT2i, but the majority were not on the maximum recommended doses. None of the patients with HFrEF and CKD G5 received quadruple therapy. Among HFmrEF patients, approximately half and two-thirds were receiving RASi and/or BB, respectively, while less than 15% received ARNI, MRA, or SGLT2i. Less than 10% of patients with HFpEF were receiving SGLT2i. CONCLUSIONS: Under real-world conditions, HF in aCKD patients is sub-optimally treated. Increased awareness of current guidelines and pragmatic trials specifically enrolling these patients represent unmet medical needs.

Ultrasound guided injections in ankle and foot.

Ultrasound guidance is particularly useful for percutaneous injections in the diagnosis and management of painful conditions of the ankle and foot. The injectates used include steroids and local anesthetics, such as lidocaine, mepivacaine, bupivacaine, ropivacaine, and platelet-rich plasma. Osteoarthritis is the main indication for joint injections. Joints amenable to being injected include the tibiotalar, subtalar, midtarsal, and metatarsophalangeal joints. Tendon injections mainly involve the Achilles, peroneus, extensors, and tibialis tendons, while plantar fascia injections are useful for treating plantar fasciitis and plantar fibromatosis. Forefoot injections include joint arthritis, intermetatarsal bursitis, and Morton neuroma. The standardized approaches and doses reviewed in this paper are based on the authors' experience and can lead to high success in symptomatic relief for various conditions. These injections can be curative or serve as a guide to identify the source of pain when surgery or other therapeutic options are planned.

Factors influencing vertebral collapse in osteoporotic vertebral fractures: a case-control study of symptomatic patients attended in the emergency department.

This study aimed to identify risk factors for the collapse of osteoporotic vertebral fractures (OVFs). We analyzed data from conventional radiography and computed tomography in patients with OVFs and found that older age and two radiological measurements were predictive for vertebral collapse. These factors can be useful for clinical practice. PURPOSE: To identify risk factors for collapse of osteoporotic vertebral fractures (OVF) on computed tomography (CT) and conventional radiography (CR). METHODS: This is a retrospective case-control study including a series of patients with OVF diagnosed at the emergency department of our institution from January to September 2019. Inclusion criteria were to have standing CR and supine CT within 2 weeks after the diagnosis of OVF and a follow-up CR at 6 months or later. We evaluated different imaging measurements at the initial diagnostic examinations, including vertebral height loss, local kyphosis, vertebral density, and fracture type according to the grading systems of Genant, Sugita, Association of Osteosynthesis (AO) Spine, and the German Society for Orthopaedics and Trauma. Vertebral collapse was defined as loss of ≥ 50% of vertebral area or height. Cases and controls were defined as OVFs which collapse and do not collapse, respectively, on follow-up. RESULTS: Fifty-six patients were included in the study, with a mean age of 72.6 ± 1.2 years, including 48 women. Twenty-five (44.6%) OVFs developed collapse on follow-up. None of the fracture classification systems were found to be predictive of collapse. Multivariate analysis showed that older age, increased density ratio (≥ 2) between the fractured and non-fractured vertebral bodies, and a ≥ 6% difference in posterior vertebral height (PVH) loss between standing CR and supine CT exhibited 88% discriminative power in predicting vertebral collapse. CONCLUSIONS: Age over 72.5 years, a density ratio ≥ 2 between the fractured and non-fractured vertebral bodies, and a difference equal to or higher than 6% in PVH loss between standing CR and supine CT, are risk factors for developing vertebral collapse after OVF.

Anti-Spike antibodies 3 months after SARS-CoV-2 mRNA vaccine booster dose in patients on hemodialysis: the prospective SENCOVAC study.

Background: Patients on hemodialysis are at high-risk for complications derived from coronavirus disease 2019 (COVID-19). The present analysis evaluated the impact of a booster vaccine dose and breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections on humoral immunity 3 months after the booster dose. Methods: This is a multicentric and prospective study assessing immunoglobulin G anti-Spike antibodies 6 and 9 months after initial SARS-CoV-2 vaccination in patients on hemodialysis that had also received a booster dose before the 6-month assessment (early booster) or between the 6- and 9-month assessments (late booster). The impact of breakthrough infections, type of vaccine, time from the booster and clinical variables were assessed. Results: A total of 711 patients [67% male, median age (range) 67 (20-89) years] were included. Of these, 545 (77%) received an early booster and the rest a late booster. At 6 months, 64 (9%) patients had negative anti-Spike antibody titers (3% of early booster and 29% of late booster patients, P = .001). At 9 months, 91% of patients with 6-month negative response had seroconverted and there were no differences in residual prevalence of negative humoral response between early and late booster patients (0.9% vs 0.6%, P = .693). During follow-up, 35 patients (5%) developed breakthrough SARS-CoV-2 infection. Antibody titers at 9 months were independently associated with mRNA-1273 booster (P = .001), lower time from booster (P = .043) and past breakthrough SARS-CoV-2 infection (P < .001). Conclusions: In hemodialysis patients, higher titers of anti-Spike antibodies at 9 months were associated with mRNA-1273 booster, lower time from booster and past breakthrough SARS-CoV-2 infection.

Painful insight vs. usable insight in schizophrenia. Do they have different influences on suicidal behavior?

BACKGROUND: Suicidal behavior is highly prevalent in schizophrenia. Among the risk factors, insight has been little studied and has yielded contradictory results. In addition, it has been studied neglecting relevant psychological aspects, such as beliefs about illness and coping styles. METHOD: We assessed 133 outpatients diagnosed with schizophrenia according to ICD-10 criteria. Evaluation included sociodemographic, general clinical, psychopathological, psychological and suicidal behavior variables. RESULTS: Neither insight nor insight coupled with negative beliefs and/or coping styles were associated with suicidal behavior. Nevertheless, insight coupled with negative beliefs and/or coping styles was associated with greater hopelessness and depression, internalized stigma, worse control over illness and greater global severity as compared to insight coupled with positive beliefs and coping styles. Suicide attempt and suicidal ideation groups showed greater depression and hopelessness, worse global beliefs and worse control over illness, higher socio-economic level, and greater number of previous psychiatric admissions compared to the non-suicidal group. CONCLUSIONS: Insight coupled with negative beliefs and/or coping style was not associated with suicidal behavior. Nevertheless, it was associated with greater depression and hopelessness, both of which are firmly established risk factors for suicide in schizophrenia. Prospective studies with long-term follow-up and large samples are needed to clarify this issue. Clinicians should assess these psychological features associated with insight, both in patients with insight and in those with poor insight when promoting it.

Resultados en el tratamiento de traumatismos esplénicos utilizando un protocolo multidisciplinar en 110 pacientes consecutivos en un hospital de nivel II / Management of Splenic Injuries Utilizing a Multidisciplinary Protocol in 110 Consecutive Patients at a Level II Hospital

INTRODUCCIÓN: El tratamiento no operatorio (TNO) de los traumatismos esplénicos es el manejo de elección en pacientes estables hemodinámicamente. El objetivo del presente estudio fue valorar la tasa de fracaso del TNO tras la implantación de un protocolo multidisciplinar para las lesiones esplénicas y comparar los resultados con la literatura. MÉTODOS: Estudio retrospectivo, de 16 años de duración. Se registró el manejo de estas lesiones según nuestro protocolo hospitalario, datos demográficos, presión arterial, frecuencia respiratoria, Escala de Coma de Glasgow, Revised Trauma Score, Injury Severy Score, gradación de las lesiones según la American Association for the Surgery of Trauma, fracaso del TNO, morbimortalidad. RESULTADOS: Se incluyó a 110 pacientes: 90 (81,8%) varones (81,8%), 20 (18,2%) mujeres; edad media de 37 años; 106 (96,5%) casos fueron contusos y 4 (3,5%) penetrantes por arma blanca. El diagnóstico se estableció mediante ECO/TAC. La clasificación de la American Association for the Surgery of Trauma fue: 14 (13%) pacientes fueron grado I; 24 (22%) grado II; 34 (31%) grado III; 37 (34%) grado IV. Se realizó laparotomía de urgencia en 54 pacientes: 37 por lesiones grado IV y en 17 por inestabilidad hemodinámica. En 56 pacientes se instauró TNO, cirugía conservadora en 16 y esplenectomía en 38. Diez pacientes presentaron complicaciones postoperatorias: 7 en el grupo de esplenectomía, 2 en el grupo de cirugía conservadora y uno en el de TNO (que requirió intervención por fracaso en TNO). La mortalidad fue de un paciente. Estancia media: 22,8 días; TNO 17,6 días; cirugía conservadora 29; esplenectomía 22,4 días. CONCLUSIONES: Si bien continuamos con una estancia hospitalaria elevada, nuestros resultados son comparables a los de la literatura. La implantación consensuada del protocolo contribuyó al cambio hacia TNO

INTRODUCTION: Non-operative treatment (NOM) of splenic trauma is the management of choice in hemodynamically stable patients. The aim of the present study was to assess the failure rate of NOM after implementation of a multidisciplinary protocol for splenic injuries compared to literature results. METHODS: A retrospective study was performed over a 16-year period. Patient data and management of splenic trauma was recorded according to our hospital protocol: demographic data, blood pressure, respiratory rate, Glasgow Coma Scale(GCS), Revised Trauma Score(RTS), Injury Severity Score(ISS), injury grade according to the American Association for the Surgery of Trauma(AAST), failure of NOM, morbidity and mortality. RESULTS: One hundred ten patients were included: 90(81.8%) men, 20 (18.2%) women; mean age 37 years; 106(96.5%) cases were blunt and four(3.5%) penetrating by knife. The diagnosis was established by US/CT. AAST classification: 14(13%) grade I; 24 (22%) grade II; 34 (31%) grade III; 37(34%) grade IV. Emergency laparotomy was performed in 54 patients: 37 due to grade IV injuries, 17 due to hemodynamic instability. NOM was utilized in 56 patients, spleen-preserving surgery in 16, and splenectomy in 38. Ten patients had postoperative complications: seven in the splenectomy group, two in the spleen-preserving surgery group, and one in the NOM group. One patient died. Average hospital stay: 22.8 days- NOM 17.6 days, conservative surgery 29 days, splenectomy 22.4 days. CONCLUSIONS: Although we continue with a high hospital stay, the literature reports support our results. The implementation of the protocol by consensus contributed to the change towards NOM

Association of Urinary Levels of Bisphenols A, F, and S with Endometriosis Risk: Preliminary Results of the EndEA Study.

Aim: The aim of this study was to explore associations of urinary concentrations of bisphenols A (BPA), S (BPS), and F (BPF) and of thiobarbituric acid reactive substances (TBARS) with the risk of endometriosis in women of childbearing age. Methods: This case-control study enrolled 124 women between January 2018 and July 2019: 35 women with endometriosis (cases) and 89 women without endometriosis undergoing abdominal surgery for other reasons (controls). Endometriosis was diagnosed (cases) or ruled out (controls) by laparoscopic inspection of the pelvis and the biopsy of suspected lesions (histological diagnosis). Fasting urine samples were collected before surgery to determine concentrations of BPA, BPS, BPF, and TBARS. Associations of bisphenol and TBARS concentrations with endometriosis risk were explored with multivariate logistic and linear regression analyses. Results: After adjustment for urinary creatinine, age, BMI, parity, and residence, endometriosis risk was increased with each 1 log unit of BPA [OR 1.5; 95%CI 1.0-2.3] and Σbisphenols [OR 1.5; 95%CI 0.9-2.3] but was not associated with the presence of BPS and BPF. Classification of the women by tertiles of exposure revealed statistically significant associations between endometriosis risk and the second tertile of exposure to BPA [OR 3.7; 95%CI 1.3-10.3] and Σbisphenols [OR 5.4; 95%CI 1.9-15.6]. In addition, TBARS concentrations showed a close-to-significant relationship with increased endometriosis risk [OR 1.6; 95%CI 1.0-2.8], and classification by TBARS concentration tertile revealed that the association between endometriosis risk and concentrations of BPA [OR 2.0; 95%CI 1.0-4.1] and Σbisphenols [OR 2.2; 95%CI 1.0-4.6] was only statistically significant for women in the highest TBARS tertile (>4.23 µM). Conclusion: Exposure to bisphenols may increase the risk of endometriosis, and oxidative stress may play a crucial role in this association. Further studies are warranted to verify these findings.

Management of Splenic Injuries Utilizing a Multidisciplinary Protocol in 110 Consecutive Patients at a Level II Hospital. / Resultados en el tratamiento de traumatismos esplénicos utilizando un protocolo multidisciplinar en 110 pacientes consecutivos en un hospital de nivel II.

INTRODUCTION: Non-operative treatment (NOM) of splenic trauma is the management of choice in hemodynamically stable patients. The aim of the present study was to assess the failure rate of NOM after implementation of a multidisciplinary protocol for splenic injuries compared to literature results. METHODS: A retrospective study was performed over a 16-year period. Patient data and management of splenic trauma was recorded according to our hospital protocol: demographic data, blood pressure, respiratory rate, Glasgow Coma Scale(GCS), Revised Trauma Score(RTS), Injury Severity Score(ISS), injury grade according to the American Association for the Surgery of Trauma(AAST), failure of NOM, morbidity and mortality. RESULTS: One hundred ten patients were included: 90(81.8%) men, 20(18.2%) women; mean age 37 years; 106(96.5%) cases were blunt and four(3.5%) penetrating by knife. The diagnosis was established by US/CT. AAST classification: 14(13%) grade I; 24(22%) grade II; 34(31%) grade III; 37(34%) grade IV. Emergency laparotomy was performed in 54 patients: 37 due to grade IV injuries, 17 due to hemodynamic instability. NOM was utilized in 56 patients, spleen-preserving surgery in 16, and splenectomy in 38. Ten patients had postoperative complications: seven in the splenectomy group, two in the spleen-preserving surgery group, and one in the NOM group. One patient died. Average hospital stay: 22.8 days- NOM 17.6 days, conservative surgery 29 days, splenectomy 22.4 days. CONCLUSIONS: Although we continue with a high hospital stay, the literature reports support our results. The implementation of the protocol by consensus contributed to the change towards NOM.

Dilatación quística de la vía biliar Todani Ic / Todani Ic cystic dilatation of the bile duct

No disponible

Todani Ic cystic dilatation of the bile duct.

The congenital dilation of the bile duct is an infrequent pathology in western countries and is associated with the female sex. It is usually diagnosed clinically with complementary tests and evaluated at an early age and also appears frequently in adults. These dilatations are grouped into five types according to Todani's classification, including type Ic (Figure 1). The treatment of choice for dilatations of the biliary duct Todani type I is the complete excision of the biliary tract due to the susceptibility of malignant degeneration. A reconstruction is performed via a hepaticojejunostomy with a Roux-en-Y loop. Although in non-malignant cases, a papillotomy with prophylactic stent placement using ERCP can be performed as an alternative. We present the case of a 54-year-old female with a history of high blood pressure, she was examined due to generalized abdominal pain which was unrelated to food intake. The blood test did not identify any alterations of interest. Ultrasound identified a fusiform dilation of the common bile duct occupied by lithiasis. ERCP was attempted due to choledocholithiasis, but the procedure was abandoned as it was not feasible to channel the duodenal papilla. The study was completed with NMR cholangiography (transverse plane [Figure 2] and coronal plane [Figure 3]), identifying a diffuse fusiform dilatation of the common bile duct and common hepatic duct, compatible with congenital cystic lesion Todani type Ic. Finally, the patient underwent a hepaticojejunostomy after sectioning of the main bile duct and extraction of choledocholithiasis.

Chronic kidney disease staging with cystatin C or creatinine-based formulas: flipping the coin.

Background: Chronic kidney disease (CKD) affects 10-13% of the population worldwide. CKD classification stratifies patients in five stages of risk for progressive renal disease based on estimated glomerular filtration rate (eGFR) by formulas and albuminuria. However, the reliability of formulas to reflect real renal function is a matter of debate. The effect of the error of formulas in the CKD classification is unclear, particularly for cystatin C-based equations. Methods: We evaluated the reliability of a large number of cystatin C and/or creatinine-based formulas in the definition of the stages of CKD in 882 subjects with different clinical situations over a wide range of glomerular filtration rates (GFRs) (4.2-173.7 mL/min). Results: Misclassification was a constant for all 61 formulas evaluated and averaged 50% for creatinine-based and 35% for cystatin C-based equations. Most of the cases were misclassified as one stage higher or lower. However, in 10% of the subjects, one stage was skipped and patients were classified two stages above or below their real stage. No clinically relevant improvement was observed with cystatin C-based formulas compared with those based on creatinine. Conclusions: The error in the classification of CKD stages by formulas was extremely common. Our study questions the reliability of both cystatin C and creatinine-based formulas to correctly classify CKD stages. Thus the correct classification of CKD stages based on estimated GFR is a matter of chance. This is a strong limitation in evaluating the severity of renal disease, the risk for progression and the evolution of renal dysfunction over time.

Relación entre enfermedad periodontal y afecciones respiratorias en pacientes ingresados en sala de Medicina Interna / Relationship between periodontal disease and respiratory conditions in patients admitted to the Internal Medicine ward

Fundamento: la enfermedad periodontal puede constituir un factor de riesgo para las enfermedades respiratorias, al estar el tracto respiratorio en relación estrecha con la cavidad oral. Objetivo: describir la asociación entre enfermedad periodontal y enfermedades respiratorias. Métodos: estudio descriptivo, prospectivo, de serie de casos sobre los pacientes ingresados en Servicio de Medicina Interna entre septiembre de 2015 y enero de 2016, con enfermedades respiratorias agudas o crónicas descompensadas y por más de cinco días en el servicio. A cada enfermo se le realizó examen estomatológico en la primera semana tras el ingreso. Se analizaron: sexo, edad, tipo de afección periodontal observada y enfermedad respiratoria que presentaban, así como factores de riesgo. La información se recopiló a través de las historias clínicas, cuestionario y examen bucal. Resultados: todos los pacientes con enfermedad respiratoria tenían algún tipo de lesión que los incluía dentro de alguno de los estados periodontales; los más frecuentes fueron la formación de bolsas entre 4 y 5 mm (70, 3 %) y el sangrado gingival (33,3 %). El factor de riesgo que predominó para ambos grupos de enfermedades fue el hábito de fumar. Conclusiones: existe una relación entre las enfermedades periodontales y respiratorias agudas o crónicas descompensadas. Ambas enfermedades tienen factores de riesgo comunes.

Foundation: periodontal disease may be a risk factor for respiratory diseases as long as the respiratory tract is in close relation to the oral cavity.Objective: to describe the asossciation between periodontal disease and respiratory diseases. Methods: descriptive, prospective study of series of cases. Universe, admitted patients to the Internal Medicine Service from September 2015 to January 2016, with decompensated acute or chronic respiratory diseases and for more than five days in the service. Each patient underwent a dental examination in the first week after admission. The following variables were analyzed: sex, age, type of observed periodontal disease and respiratory disease that they presented, as well as risk factors. The information was collected through medical records, questionnaire and oral examination. Results: all patients with respiratory disease had some type of injury which included them within any of the periodontal conditions; the most frequent were the formation of bags between 4 and 5 mm (70.3%) and gingival bleeding (33.3%). The predominating risk factor for both groups of diseases was the smoking habit. Conclusion: there is a relationship between acute and chronic decompensated periodontal and respiratory diseases. Both diseases have common risk factors.

Duodenectomía parcial como opción terapéutica de un tumor del estroma gastrointestinal duodenal múltiple, asociado a neurofibromatosis tipo 1 / Partial duodenectomy as a therapeutic option in multiple duodenal gastrointestinal stromal tumour associated with neurofibromatosis type 1

No disponible

Colecistitis aguda por Listeria monocytogenes en paciente inmunocompetente / Listeria monocytogenes cholecystitis in an immunocompetent patient

No disponible

Tumor desmoplásico de células redondas pequeñas peritoneal. Una entidad infrecuente con un mal pronóstico / Desmoplastic small-round-cell tumor of the peritoneum: An uncommon entity with poor prognosis

No disponible

[Acute abdomen due to complicated intramural duodenal haematoma. Report of a case and review of the literature]. / Abdomen agudo por hematoma duodenal intramural complicado. Presentación de un caso y revisión en la literatura.

BACKGROUND: Intramural duodenal haematoma is a rare entity that usually occurs in the context of patients with coagulation disorders. A minimum percentage is related to processes such as pancreatitis and pancreatic tumours. CLINICAL CASE: The case is presented of a 45 year-old male with a history of chronic pancreatitis secondary to alcoholism. He was seen in the emergency room due to abdominal pain, accompanied by toxic syndrome. The abdominal computed tomography reported increased concentric duodenal wall thickness, in the second and third portion. After oesophageal-gastro-duodenoscopy, he presented with haemorrhagic shock. He had emergency surgery, finding a hemoperitoneum, duodenopancreatic tumour with intense inflammatory component, as well a small bowel perforation of third duodenal portion. A cephalic duodenopancreatectomy was performed with pyloric preservation and reconstruction with Roux-Y. DISCUSSION: Treatment of a duodenal haematoma is nasogastric decompression, blood transfusion and correction of coagulation abnormalities. Surgery is indicated in the cases in which there is no improvement after 2 weeks of treatment, or there is suspicion of malignancy or major complications arise. CONCLUSIONS: Duodenal intramural haematoma secondary to chronic pancreatitis is rare, although the diagnosis should be made with imaging and, if suspected, start conservative treatment and surgery only in complicated cases.

Tratamiento conservador de la perforación duodenal tras realización de colangiopancreatografía retrógrada endoscópica terapéutica / Conservative treatment of duodenal perforation after therapeutic endoscopic retrograde cholangiopancreatography

No disponible