Luxación tibiofibular proximal diagnóstico y tratamiento / Proximal tibiofibular joint dislocation diagnosis and treatment

Resumen: Introducción: La luxación tibiofibular proximal (LTFP) es una lesión poco frecuente y no diagnosticada. De no ser tratada a tiempo, puede generar una sintomatología crónica de dolor e inestabilidad. La escasa evidencia disponible no entrega un protocolo de enfrentamiento ni consenso respecto a su manejo. Con el objetivo de asistir al enfrentamiento de esta lesión, se presenta una revisión de la literatura de una LTFP con reducción espontánea. Caso clínico: Hombre de 22 años consulta por dolor intenso en su rodilla derecha, posterior a caída en cuatrimoto. Al examen físico con aumento de volumen doloroso en cara lateral de la rodilla y pierna proximal, con movilidad completa y estable. Radiografías son informadas sin alteraciones. Se mantiene la sospecha clínica de LTFP, se continúa estudio con resonancia magnética (RM), la que es sugerente de LTFP. Dentro de las 24 horas de evolución, el paciente indica haber sentido un clank espontáneo en su rodilla afectada con cese completo de sintomatología. Se sigue al paciente por tres meses con RM de control, manteniendo una rodilla asintomática; examen físico y funcionalidad normal. Conclusión: El diagnóstico de las LTFP requiere un adecuado uso de imágenes. Su manejo consiste en una reducción cerrada de urgencia y de no lograrse, una reducción abierta, reparación y fijación interna. El pronóstico de las reducciones espontáneas es incierto, por lo que deben ser seguidas de forma seriada y en caso de recidiva, manejadas quirúrgicamente según el tiempo de evolución.

Abstract: Introduction: Proximal tibiofibular joint dislocations (PTFJD) are uncommon and underdiagnosed injuries. Urgent reduction is mandatory to avoid chronic disfunction. The scarcely available literature does not present a unified management guideline. An acute PTFJD case report with spontaneous reduction and a review of the literature is presented, aiming to assist the diagnosis and management of this pathology. Case report: A 22-years old male presented to the emergency department with high intensity right knee pain after falling in a four-wheel motorcycle. The physical exam revealed a prominent painful mass on the lateral aspect of his knee and proximal leg. His range of motion and knee stability were unremarkable. X-rays were informed negative for musculoskeletal injuries. According to a sustained suspicion of PTFJD, the study was continued with a magnetic resonance imaging (MRI), which suggested PTFJD. During the following 24 hours, the patient referred he was entirely asymptomatic after feeling a loud «clank¼. He has been followed for three months with MRI, and remains asymptomatic with full functions. Conclusion: PTFJD diagnosis requires appropriate images. Urgent close reduction is mandatory; if unsuccessful, open reduction, primary repair and internal fixation are indicated. The prognosis of spontaneous reduction remains uncertain and requires a serial clinical evaluation. In the case of recurrence, the appropriate surgical management is indicated according to the elapsed time from the injury.

[Proximal tibiofibular joint dislocation diagnosis and treatment]. / Luxación tibiofibular proximal diagnóstico y tratamiento.

INTRODUCTION: Proximal tibiofibular joint dislocations (PTFJD) are uncommon and underdiagnosed injuries. Urgent reduction is mandatory to avoid chronic disfunction. The scarcely available literature does not present a unified management guideline. An acute PTFJD case report with spontaneous reduction and a review of the literature is presented, aiming to assist the diagnosis and management of this pathology. CASE REPORT: A 22-years old male presented to the emergency department with high intensity right knee pain after falling in a four-wheel motorcycle. The physical exam revealed a prominent painful mass on the lateral aspect of his knee and proximal leg. His range of motion and knee stability were unremarkable. X-rays were informed negative for musculoskeletal injuries. According to a sustained suspicion of PTFJD, the study was continued with a magnetic resonance imaging (MRI), which suggested PTFJD. During the following 24 hours, the patient referred he was entirely asymptomatic after feeling a loud "clank". He has been followed for three months with MRI, and remains asymptomatic with full functions. CONCLUSION: PTFJD diagnosis requires appropriate images. Urgent close reduction is mandatory; if unsuccessful, open reduction, primary repair and internal fixation are indicated. The prognosis of spontaneous reduction remains uncertain and requires a serial clinical evaluation. In the case of recurrence, the appropriate surgical management is indicated according to the elapsed time from the injury.

INTRODUCCIÓN: La luxación tibiofibular proximal (LTFP) es una lesión poco frecuente y no diagnosticada. De no ser tratada a tiempo, puede generar una sintomatología crónica de dolor e inestabilidad. La escasa evidencia disponible no entrega un protocolo de enfrentamiento ni consenso respecto a su manejo. Con el objetivo de asistir al enfrentamiento de esta lesión, se presenta una revisión de la literatura de una LTFP con reducción espontánea. CASO CLÍNICO: Hombre de 22 años consulta por dolor intenso en su rodilla derecha, posterior a caída en cuatrimoto. Al examen físico con aumento de volumen doloroso en cara lateral de la rodilla y pierna proximal, con movilidad completa y estable. Radiografías son informadas sin alteraciones. Se mantiene la sospecha clínica de LTFP, se continúa estudio con resonancia magnética (RM), la que es sugerente de LTFP. Dentro de las 24 horas de evolución, el paciente indica haber sentido un clank espontáneo en su rodilla afectada con cese completo de sintomatología. Se sigue al paciente por tres meses con RM de control, manteniendo una rodilla asintomática; examen físico y funcionalidad normal. CONCLUSIÓN: El diagnóstico de las LTFP requiere un adecuado uso de imágenes. Su manejo consiste en una reducción cerrada de urgencia y de no lograrse, una reducción abierta, reparación y fijación interna. El pronóstico de las reducciones espontáneas es incierto, por lo que deben ser seguidas de forma seriada y en caso de recidiva, manejadas quirúrgicamente según el tiempo de evolución.

Guía clínica española del acceso vascular para hemodiálisis / Spanish clinical guidelines on vascular access for haemodialysis

El acceso vascular para hemodiálisis es esencial para el enfermo renal tanto por su morbimortalidad asociada como por su repercusión en la calidad de vida. El proceso que va desde la creación y mantenimiento del acceso vascular hasta el tratamiento de sus complicaciones constituye un reto para la toma de decisiones debido a la complejidad de la patología existente y a la diversidad de especialidades involucradas. Con el fin de conseguir un abordaje consensuado, el Grupo Español Multidisciplinar del Acceso Vascular (GEMAV), que incluye expertos de las cinco sociedades científicas implicadas (nefrología [S.E.N.], cirugía vascular [SEACV], radiología vascular e intervencionista [SERAM-SERVEI], enfermedades infecciosas [SEIMC] y enfermería nefrológica [SEDEN]), con el soporte metodológico del Centro Cochrane Iberoamericano, ha realizado una actualización de la Guía del Acceso Vascular para Hemodiálisis publicada en 2005. Esta guía mantiene una estructura similar, revisando la evidencia sin renunciar a la vertiente docente, pero se aportan como novedades, por un lado, la metodología en su elaboración, siguiendo las directrices del sistema GRADE con el objetivo de traducir esta revisión sistemática de la evidencia en recomendaciones que faciliten la toma de decisiones en la práctica clínica habitual y, por otro, el establecimiento de indicadores de calidad que permitan monitorizar la calidad asistencial.

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support.

Corneal densitometry after photorefractive keratectomy, laser-assisted in situ keratomileusis, and small-incision lenticule extraction.

PurposeThe aim of this study was to gain greater insight into the corneal densitometry changes occurring as a result of refractive surgery and to compare these changes across three widely used surgical techniques, namely, photorefractive keratectomy (PRK), laser-assisted in situ keratomileusis with a femtosecond laser (LASIK-FS), or ReLEx small-incision lenticule extraction (ReLEx SMILE).Patients and methodsThree hundred and thirty-six patients (184 male and 152 female patients) participated in this study. They were split into three groups according to the refractive surgery technique they had undergone: LASIK-FS (74 patients), PRK (153 patients), and ReLEx SMILE (109 patients). All participants underwent an exhaustive eye examination both before and after surgery. Pre- and postoperative corneal densitometry was measured using an Oculus Pentacam system.ResultsThe mean postoperative total corneal densitometry values were 16.53±1.94 for the LASIK-FS group, 15.53±1.65 for PRK, and 16.10±1.54 for ReLEx SMILE. When corneal densitometry was analyzed for specific corneal areas, the values corresponding to the 0-2, 2-6, and 6-10 mm annuli were similar across the three surgical techniques. The only region in which differences were found was the peripheral area (P<0.05), but these variations across techniques were not statistically significant.ConclusionsCorneal densitometry can be used as an objective metric to assess corneal response to refractive surgery, and to monitor patients over time. Corneal densitometry was not negatively affected by any of the refractive surgical procedures under evaluation.

Takotsubo's cardiomyopathy in the preoperative period of an emergent abdominal surgical procedure / Cardiomiopatía de Takotsubo en el periodo preoperatorio de un procedimiento quirúrgico urgente

No disponible

Neurología y síndrome de Down. Desarrollo y atención temprana / Neurology and Down syndrome. Development and early intervention

Aunque los avances diagnósticos y terapéuticos han contribuido a mejorar las afecciones orgánicas de los pacientes con síndrome de Down (cardiopatías, malformaciones digestivas, hipotiroidismo, etc.), el retraso psicomotor continúa siendo el factor más discapacitante para una persona con trisomía. En ausencia de tratamiento curativo, la atención temprana a las distintas áreas del desarrollo es el arma más eficaz para procurar la integración de estos pacientes. Por ello, desde la época neonatal o de la lactancia precoz, los niños deben ser dirigidos a Unidades multidisciplinares en las que se aborden los distintos aspectos del desarrollo infantil (AU)

Although the diagnostic and therapeutic advances have contributed to improving the organic conditions of patients with Down's Syndrome (heart diseases, digestive malformations, hypothyroidism, etc.), psychomotor retardation continues o be the most incapacitating factor for a person with trisomy. In absence of curative treatment, early attention to the different development areas is the most effective tool to seek the integration f these patients. Thus, from the neonatal or early lactation period, the children should been referred to multidisciplinary units where the different aspects of child development are approached (AU)

Hemorragia digestiva alta como complicación de un síndrome de Budd-Chiari: reporte de un caso / High digestive hemorrhage resulting from a Budd-Chiari syndrome complication: case report

INTRODUCCIÓN: El Síndrome de Budd-Chiari es una obstrucción del drenaje venoso hepático. Las principales etiologías son los síndromes mieloproliferativos y anti-fosfolípido. La clínica que predomina deriva insuficiencia hepática crónica igual que sus complicaciones. El diagnóstico es mediante imágenes o biopsia hepática. El tratamiento va a depender de la causa y tiene una supervivencia de 75 por ciento a diez años. PRESENTACIÓN DEL CASO Mujer de 26 años con antecedentes de Policitemia Vera, Síndrome de Budd-Chiari y aborto espontáneo secundario a trombosis placentaria, consulta en Servicio de Urgencia del Hospital San Juan de Dios de San Fernando por vómitos rojizos asociados a melena. A su ingreso se plantearon los siguientes diagnósticos: hemorragia digestiva alta, anemia severa, anasarca, síndrome de Budd-Chiari, Policitemia Vera e insuficiencia hepática crónica; además de Child-Pugh C. La paciente se hospitaliza en Unidad de Cuidados Intermedios con tratamiento en base a suero fisiológico, transfusiones sanguíneas, omeprazol, vitamina K y furosemida. Endoscopia digestiva alta revela signos de hipertensión portal y várices esofágicas medianas con signo rojo presente. Luego de ocho días de hospitalización cede la hemorragia digestiva y se decide dar el alta, con control en siete días. DISCUSIÓN: El sangrado gastrointestinal es una complicación que alcanza un 10 por ciento a 15 por ciento en pacientes con síndrome de Budd-Chiari, y puede ocurrir en los que están recibiendo terapia anticoagulante, así como en aquellos con hipertensión portal secundaria a insuficiencia hepática crónica.

INTRODUCTION: Budd-Chiari syndrome is an obstruction of hepatic venous drainage. The main causes are myeloproliferative and anti-phospholipid syndromes. The predominant clinical results are from chronic liver failure as well as its complications. Diagnosis is by imaging or liver biopsy. Treatment will depend on the cause and have a survival of 75 percent at ten years. CASE REPORT: A 26 year old woman with history of polycythemia vera, Budd-Chiari syndrome and spontaneous abortion secondary to placental thrombosis, consulted in the Emergency Service in Hospital San Juan de Dios of San Fernando because of red vomits associated with melena. On admission were raised the following diagnoses: Upper gastrointestinal tract hemorrhage, severe anemia, anasarca, Budd Chiari Syndrome, Polycythemia Vera and Chronic Liver failure; Child-Pugh C. The patient was hospitalized on intermediate care unit with treatment based on physiological saline, blood transfusions, omeprazole, vitamin K and furosemide. Upper gastrointestinal endoscopy revealed signs of portal hypertension and esophageal medium varices with red sign. After eight days hospitalized, gastrointestinal bleeding stops, the patient is discharged and control is decided in seven more days. DISCUSSION: Gastrointestinal bleeding is a complication that achieves 10 percent to 15 percent in patients with Budd-Chiari syndrome, and can occur in the ones who are receiving anticoagulant therapy, as well in those with portal hypertension secondary to chronic liver failure.

[Vascular access models cause heterogeneous results in the centres of one community]. / Los modelos de atención al acceso vascular condicionan resultados heterogéneos en los centros de una misma comunidad.

INTRODUCTION: Vascular access (VA) is the main difficulty in our hemodialysis Units and there is not adequate update data in our area. PURPOSE: To describe the vascular access management models of the Autonomous Community of Madrid and to analyze the influence of the structured models in the final results. MATERIAL AND METHODS: Autonomous multicenter retrospective study. Models of VA monitoring, VA distribution 2007-2008, thrombosis rate, salvage surgery and preventive repair are reviewed. The centers are classified in three levels by the evaluation the Nephrology Departments make of their Surgery and Radiology Departments and the existence of protocols, and the ends are compared. MAIN VARIABLES: Type distribution of VA. VA thrombosis rate, preventive repair and salvage surgery. RESULTS: Data of 2.332 patients were reported from 35 out of 36 centers. Only 19 centers demonstrate database and annual evaluation of the results. Seventeen centers have multidisciplinary structured protocols. Forty-four point eight percent of the patients started dialysis by tunneled catheter (TC). Twenty-nine point five percent received dialysis by TC in December-08 vs 24.7% in December-07. Forty-four point seven percent of TC were considered final VA due to non-viable surgery, 27% are waiting for review or surgery more than 3 months. For rates study data from 27 centers (1.844 patients) were available. Native AVF and graft-AVF thrombosis rates were 10.13 and 39.91 respectively. Centers with better valued models confirmed better results in all markers: TC rates, 24.2 vs 34.1 %, p: 0.002; native AVF thrombosis rate 5.3 vs 10.7 %; native AVF preventive repair 14.5 vs 10.2%, p: 0.17; Graft- AVF thrombosis rate 19.8 vs 44.4%, p: 0.001; Graft-AVF preventive repair 83.2 vs 26.2, p < 0.001.They also have less patients with TC as a final option (32.2 vs 45.3) and less patients with TC waiting for review or surgery more than 3 months (2.8 vs 0). LIMITS: Seventy-five percent of patients were reached for the analysis of thrombosis rate. Results are not necessarily extrapolated. CONCLUSIONS: For the first time detailed data are available. TC use is elevated and increasing. Guidelines objectives are not achieved. The difference of results observed in different centers of the same public health area; make it necessary to reevaluate the various models of care and TC follow-up.

Single molecule PCR in mtDNA mutational analysis: Genuine mutations vs. damage bypass-derived artifacts.

The area of somatic mtDNA mutation measurement is in a crisis because the methods used to quantify mtDNA mutations produce results varying by multiple orders of magnitude. The reason for these discrepancies is not clear, but given that most methods involve PCR, the prime suspect is PCR artifacts (e.g. spontaneous errors by the DNA polymerases used). In addition to simple misincorporation, another important source of artificial mutations is the conversion of chemically modified (e.g. damaged) nucleotides into mutations when bypassed by a thermostable DNA polymerase. These latter mutations are particularly difficult to account for because appropriate controls are not available. Here, we argue that single molecule PCR (smPCR) is uniquely positioned to account for these bypass-related artificial mutations and discuss the methodology involved in employing this technique.

Valoración de las calcificaciones coronarias / Multidetector Row CT in assessment of coronary artery calcification on hemodialisis

La calcificación vascular es un potente predictor de mortalidad cardiovascular y global. Las calcificaciones de las arterias coronarias en pacientes renales son más frecuentes, más extensas y progresan más rápidamente que en la población general y constituyen un marcador de enfermedad coronaria de elevada prevalencia y significación funcional. La aparición de nuevas técnicas de imagen, como el TAC multidetector, permiten detectar y cuantificar las calcificaciones vasculares utilizando un score de calcificación similar al score de calcio del TAC emisor de electrones. Mediante TAC helicoidal de 16 filas de detectores hemos evaluado y cuantificado la presencia de calcificación de arterias coronarias y su relación con diferentes factores de riesgo cardiovascular en 44 pacientes en hemodiálisis. La prevalencia de calcificación fue del 84%, con un score de calcio medio de 1.580 ± 2.010 (r 0-9.844). El 66% delos pacientes presentaban valores de score de calcio > 400. La calcificación coronaria era por lo general múltiple, afectando a más de 2 vasos y de manera prácticamente constante a la arteria descendente anterior (97%) aunque la arteria coronaria derechapresentó valores de score de calcio más elevados. La calcificación coronaria se relacionó con edad avanzada, sexo masculino, diabetes, mayor comorbilidad, tabaquismo,antecedentes de enfermedad cerebrovascular y tratamiento con quelantes del fósforo que contenían calcio y análogos de la vitamina D. La calcificación de lasarterias coronarias es muy frecuente y extensa, normalmente múltiple y asociada a factores de riesgo cardiovascular modificables en los pacientes en hemodiálisis. El TAC Multidetector parece un método eficaz, fácil de reproducir y cómodo para el pacienteque permite detectar y cuantificar las calcificaciones coronarias

Vascular calcification is a strong predictor of cardiovascular and all-cause mortality. Coronary artery calcification is more frequent, more extensive and progresses more rapidly in CKD than in general population. They are also considered a markerof coronary heart disease, with high prevalence and functional significance. It suggests that detection and surveillance may be worthwhile in general clinical practice. New non-invasive image techniques, like Multi-detector row CT, a type of spiral scanner, assess density and volume of calcification at multiple sites and allow quantitative scoring of vascular calcification using calcium scores analogous to those from electron-beam CT. We have assessed and quantified coronary artery calcification with 16 multidetector row CT in 44 patients on hemodialysis and their relationshipwith several cardiovascular risk factors. Coronary artery calcification prevalence was of 84% with mean calcium score of 1,580 ± 2,010 (r 0-9.844) with calcium score > 400 in 66% of patients. It was usually multiple, affecting more than two vessels in more than 50%. In all but one patient, left anterior descending artery was involved with higher calcium score level at right coronary artery. Advanced age, male, diabetes,smoking,more morbidity, cerebrovascular disease previous, and calcium-binders phosphate and analogous vitamin D treatment would seem to be associated withcoronary artery calcification. Coronary artery calcification is very frequent and extensive,usually multiple and associated to modifiable risk factors in hemodialysis patients. Multi-detector-row CT seems an effective, suitable, readily applicable methodto assess and quantify coronary artery calcification

[Good virological response to pegylated interferon alfa monotherapy of chronic hepatitis C infection in hemodialysis patient]. / Buena respuesta a interferón npegilado en monoterapia en paciente con VHC + en hemodiálisis.

Liver disease caused by hepatitis C virus infection is associated to significant morbidity and mortality among patient with end stage renal disease on maintenance hemodialysis (HD). Therapy in these patients consists of Interferon, preferably pegylated Interferon (pIFN), thus Ribavirin (RBV) is not recommended for patients with impaired renal function, outside its use in controlled trials. We report a case of 35 years young woman on HD treatment, renal transplantation candidate with chronic hepatitis C virus infection, HCV RNA positive (by PCR), genotype 3a, moderate viral load, light increase of aminotransferases. Pegylated Interferon alfa-2a (135 mcg/weekly/SC) was initiated. She achieved HVC RNA negative within 12 weeks, following with pINF as monotherapy to complete 24 weeks (6 months). Sustained virologic response persisted to 24 and 48 weeks. Most important side effects were light detriment of anemia, moderate neutropenia and thombocytopenia, transitory elevation of transaminases and "flu-like" syndrome. Adverse events were well tolerated with total compliance with pIFN dose, no requiring reduce or stop the treatment. These findings confirm that hemodialysis patients with chronic hepatitis C respond well to pegylated IFN monotherapy and a long-term sustained virologic response is achieved, appears to be better tolerated with less side effects, so combination therapy with pINF plus ribavirin is not necessary in all cases.

Buena respuesta a interferón npegilado en monoterapia en paciente con VHC+ en hemodiálisis / Good virological response to pegylated interferon alfa monotherapy of chronic hepatitis C infection in hemodialysis patient

La afectación hepática causada por VHC se asocia con una elevada morbimortalidad entre pacientes con IRC en hemodiálisis (HD). En estos pacientes, el tratamiento consiste en Interferón alfa, preferiblemente Interferón pegilado (IFNp), al no estar recomendada la combinación con Ribavirina (RBV) en pacientes con afectación importante de la función renal excepto en estudios clínicos controlados. Se presenta el caso de una paciente joven en HD, con hepatopatía crónica por VHC, viremia positiva, genotipo 3a, carga viral moderada, elevación discreta de transaminasas y candidata a trasplante renal. Se inició tratamiento con IFNpegilado alfa-2a, a dosis de 135 mcg/semana/sc. A las doce semanas consigue negativizar la viremia, continuando con IFNp en monoterapia hasta completar las 24 semanas (6 meses). La viremia persiste negativa a la finalización del tratamiento y con respuesta virológica sostenida seis meses después (1 año). Los efectos secundarios más importantes han sido un ligero empeoramiento de la anemia, neutropenia y trombopenia moderada, elevación transitoria de transaminasas y discreta afectación del estado general, sin precisar reducir ni suspender la dosis pautada. Este caso confirma que los pacientes en HD con hepatopatía crónica VHC pueden responder a IFNp en monoterapia, consiguiendo una respuesta virológica sostenida a largo plazo, sin precisar necesariamente combinar con RBV, ya que la tolerancia es mejor y con menos efectos secundarios

Liver disease caused by hepatitis C virus infection is associated to significant morbidity and mortality among patients with end stage renal disease on maintenance hemodialysis (HD). Therapy in theses patients consists of Interferon, preferably pegylated Interferon (pIFN), thus Ribavirin (RBV) is not recommendaded for patients with impaired renal function, outside its use in controlled trials. We report a case of 35 years young woman on HD treatment, renal transplantation candidate with chronic hepatitis C virus infection, HCV RNA positive (by PCR), genotype 3a, moderate viral load, light increase of aminotransferases. Pegylated Interferon alfa-2a (135 mcg/weekly/SC) was initiated. She achieved HVC RNA negative within 12 weeks, following with pINF as monotherapy to complete 24 weeks (6 months). Sustained virologic response persisted to 24 and 48 weeks. Most important side effects were light detriment of anemia, moderate neutropenia and thombocytopenia, transitory elevation of transaminases and «flu-like» syndrome. Adverse events were well tolerated with total compliance with pIFN dose, no requiring reduce or stop the treatment. These findings confirm that hemodialysis patients with chronic hepatitis C respond well to pegylated IFN monotherapy and a long-term sustained virologic response is achieved, appears to be better tolerated with less side effects, so combination therapy with pINF plus ribavirin is not necessary in all cases

[Multidetector row CT in assessment of coronary artery calcification on hemodialisis]. / Valoración de las calcificaciones coronarias.

Vascular calcification is a strong predictor of cardiovascular and all-cause mortality. Coronary artery calcification is more frequent, more extensive and progresses more rapidly in CKD than in general population. They are also considered a marker of coronary heart disease, with high prevalence and functional significance. It suggests that detection and surveillance may be worthwhile in general clinical practice. New non-invasive image techniques, like Multi-detector row CT, a type of spiral scanner, assess density and volume of calcification at multiple sites and allow quantitative scoring of vascular calcification using calcium scores analogous to those from electron-beam CT. We have assessed and quantified coronary artery calcification with 16 multidetector row CT in 44 patients on hemodialysis and their relationship with several cardiovascular risk factors. Coronary artery calcification prevalence was of 84 % with mean calcium score of 1580 +/- 2010 ( r 0-9844) with calcium score > 400 in 66% of patients. It was usually multiple, affecting more than two vessels in more than 50%. In all but one patient, left anterior descending artery was involved with higher calcium score level at right coronary artery. Advanced age, male, diabetes, smoking, more morbidity, cerebrovascular disease previous, and calcium-binders phosphate and analogous vitamin D treatment would seem to be associated with coronary artery calcification. Coronary artery calcification is very frequent and extensive, usually multiple and associated to modifiable risk factors in hemodialysis patients. Multi-detector-row CT seems an effective, suitable, readily applicable method to assess and quantify coronary artery calcification.

Carbohydrate restriction does not change mitochondrial free radical generation and oxidative DNA damage.

Many previous investigations have consistently reported that caloric restriction (40%), which increases maximum longevity, decreases mitochondrial reactive species (ROS) generation and oxidative damage to mitochondrial DNA (mtDNA) in laboratory rodents. These decreases take place in rat liver after only seven weeks of caloric restriction. Moreover, it has been found that seven weeks of 40% protein restriction, independently of caloric restriction, also decrease these two parameters, whereas they are not changed after seven weeks of 40% lipid restriction. This is interesting since it is known that protein restriction can extend longevity in rodents, whereas lipid restriction does not have such effect. However, before concluding that the ameliorating effects of caloric restriction on mitochondrial oxidative stress are due to restriction in protein intake, studies on the third energetic component of the diet, carbohydrates, are needed. In the present study, using semipurified diets, the carbohydrate ingestion of male Wistar rats was decreased by 40% below controls without changing the level of intake of the other dietary components. After seven weeks of treatment the liver mitochondria of the carbohydrate restricted animals did not show changes in the rate of mitochondrial ROS production, mitochondrial oxygen consumption or percent free radical leak with any substrate (complex I- or complex II-linked) studied. In agreement with this, the levels of oxidative damage in hepatic mtDNA and nuclear DNA were not modified in carbohydrate restricted animals. Oxidative damage in mtDNA was one order of magnitude higher than that in nuclear DNA in both dietary groups. These results, together with previous ones, discard lipids and carbohydrates, and indicate that the lowered ingestion of dietary proteins is responsible for the decrease in mitochondrial ROS production and oxidative damage in mtDNA that occurs during caloric restriction.

One-tube-PCR technique for CCL2, CCL3, CCL4 and CCL5 applied to fine needle aspiration biopsies shows different profiles in autoimmune and non-autoimmune thyroid disorders.

Autoimmune thyroid diseases are characterized by lymphocytic infiltration of the thyroid gland. Chemokines are crucial in the recruitment of lymphocytes and might play an important role in the pathogenesis of autoimmune thyroid disease. The aim of this study was to test the feasibility of analysing by one-tube reverse-transcriptase polymerase chain reaction (RT-PCR) technique CC chemokine profiles in samples obtained by fine needle aspiration biopsy (FNAB). In 27 out of 35 (77%) samples, the material was sufficient for analysis and in 16 (59%) chemokines were detected, thus demonstrating the potential of this technique. Moreover, even in this small group, a statistically significant increase of CCL3 and CCL4 was found in samples from patients with autoimmune thyroid disease as compared to those with multinodular goiter. Chemokine profile measured by improved multiamplification techniques in FNAB thyroid samples may become a useful complementary tool for the management of thyroid autoimmune disease as it constitutes a source of data for research of their pathogenesis.

[Measurement of cardiac output after cardiac surgery: validation of a partial carbon dioxide rebreathing (NICO) system in comparison with continuous thermodilution with a pulmonary artery catheter]. / Medición del gasto cardíaco en el postoperatorio de cirugía cardiaca: validez de la reinhalación parcial de CO2 (NICO) frente a la termodilución continua mediante catéter de arteria pulmonar.

UNLABELLED: Cardiac output is usually monitored with a pulmonary artery catheter. However, because that method is not free of risk, devices have been designed in recent years to measure cardiac output in a way that is minimally invasive or fully noninvasive. Among such devices is the NICO monitor, which is based on a modified Fick equation (partial CO2 rebreathing). OBJECTIVE: To compare the accuracy of cardiac output measurements from the NICO monitor to measurements obtained by continuous thermodilution with a pulmonary artery catheter. MATERIAL AND METHODS: A nonprobabilistic, consecutive sample of 20 patients was enrolled in the early postoperative period after elective cardiac surgery (coronary or valve procedures) in the recovery ward. Seven measurements of cardiac output were taken simultaneously with each method in each patient. RESULTS AND CONCLUSIONS: Cardiac output estimated by the partial CO2 rebreathing method was lower than the measurement obtained by the pulmonary artery catheter. The percentage error between the 2 methods was 37%, indicating that the NICO monitor can not substitute for the traditional method. The better correlation found between normal-to-low cardiac output values and the absence of side effects of using the NICO method suggest that it might be indicated for detecting low cardiac output after cardiac surgery, especially when the risk-benefit ratio does not favor using a pulmonary artery catheter.

Medición del gasto cardíaco en el postoperatorio de cirugía cardíaca: Validez de la reinhalación parcial de CO2 (NICO(R)) frente a la termodilución continua mediante catéter de arteria pulmonar / Measurement of cardiac output after cardiac surgery: validation of a partial carbon dioxide rebreathing (NICO(R))system in comparison with continuous thermodilution with a pulmonary artery catheter

La monitorización del gasto cardíaco se ha realizado tradicionalmente a través del catéter de arteria pulmonar. Sin embargo, su uso no está exento de riesgos por lo que en los últimos años se han diseñado dispositivos con mínima o nula invasividad para el registro de este pará- metro, entre los que se encuentra el monitor NICO(R), basado en una modificación de la ecuación de Fick (reinhalación parcial de CO2 ). OBJETIVO: Comparar la precisión en la medida del gasto cardíaco del monitor NICO(R) frente a la termodilución continua por catéter de arteria pulmonar. MATERIAL Y MÉTODOS: Selección no probabilística y consecutiva a 20 pacientes en el postoperatorio inmediato de cirugía cardíaca electiva (coronaria o valvular) en la unidad de reanimación. En cada paciente se tomaron siete medidas simultáneas de gasto cardíaco por ambos métodos. RESULTADOS Y CONCLUSIONES: Se observa que la medición del gasto cardíaco por reinhalación parcial de CO2 infraestima a la obtenida por catéter de arteria pulmonar. El error porcentual encontrado entre ambos métodos de medida (37%)imposibilita que el monitor NICO(R) pueda sustituir al método tradicional. La mejor correlación encontrada para valores de gasto cardíaco norma- les-bajos junto a la ausencia de efectos adversos hace que este método pueda tener su indicación en la detección de estados de bajo gasto cardíaco en este tipo de pacientes, sobre todo cuando no hay relación beneficio- riesgo favorable para la utilización del catéter de la arteria pulmonar

Cardiac output is usually monitored with a pulmonary artery catheter. However, because that method is not free of risk, devices have been designed in recent years to measure cardiac output in a way that is minimally invasive or fully noninvasive. Among such devices is the NICO® monitor, which is based on a modified Fick equation (partial CO 2 rebreathing). OBJECTIVE: To compare the accuracy of cardiac output measurements from the NICO® monitor to measurements obtained by continuous thermo-dilution with a pulmonary artery catheter. MATERIAL AND METHODS :A non probabilistic, consecutive sample of 20 patients was enrolled in the early post- operative period after elective cardiac surgery (coronary or valve procedures)in the recovery ward. Seven measurements of cardiac output were taken simultaneously with each method in each patient. RESULTS AND CONCLUSIONS: Cardiac output estimated by the partial CO 2 rebreathing method was lower than the measurement obtained by the pulmonary artery catheter. The percentage error between the 2 methods was 37%, indicating that the NICO® monitor cannot substitute for the traditional method. The better correlation found be- tween normal-to-low cardiac output values and the absence of side effects of using the NICO® method suggest that it might be indicated for detecting low cardiac output after cardiac surgery, especially when the risk-benefit ratio does not favor using a pulmonary artery catheter

[Utility of intra-access pressure]. / La utilidad de la presión intra-acceso.

Monitoring of vascular access is essential for clinical evaluation on hemodialysis patients, detects early disfunction of access, allows adequate dialysis and decreases the morbidity associated. Although is demonstrated that intra-access pressure (IAP) is a good method of screening to evaluate arterial-venous (AV) fistulas, its utility is uncommon because its measurement requires a complex system. We would like to validate the utility of IAP monitoring using a simplified measure of IAP and its relation with other methods of screening in detecting stenoses prior to thromboses of AV grafts. We studied 24 AV grafts of 24 patients during 18 months we measured arterial pressure, mean arterial pressure (MAP), dynamic venous pressure, IAP, Kt/v, URR, recirculation index (RI), access flow and color Doppler flow, dividing the patients in two groups, with stenoses or not, if IAP/MAP > 0.5 and stenoses > 0.50 by Doppler we performed arteriography and percutaneous transluminal angioplasty with stent if stenoses exits. The values of IAP, MAP, RI were higher significantly in the stenoses group with increase of vascular access in grafts were dilation by angioplasty was made. All stenoses detected with IAP were confirmed by Doppler and arteriography but one. We conclude that IAP is an early, useful, easy, effective method in detecting stenoses of AV grafts prior to thrombosis.

[Ruptured aneurysms presenting with subdural hematoma: management without angiography]. / Hematomas subdurales de causa aneurismática: estrategia terapéutica sin angiografía diagnóstica.

INTRODUCTION: Ruptured aneurysms on rare occasions cause subdural hematomas as described in literature. Sudden deterioration and coma is a common feature in those patients and a emergent surgical attitude is prompt required, even without confirmation with angiography. CASE REPORTS: We described three cases with acute subdural hematomas and little or no subarachnoid hemorrhage caused by ruptured aneurisms who presented with rapid neurologic deterioration. Urgent craniotomy and evacuation of the hematoma was performed without previous angiography in the three patients. In two patients the aneurysm was found during surgical exploration and subsequently clipped; in the remaining patient the aneurysm was embolized postoperatively. CONCLUSIONS: The occurrence of a subdural hematoma caused by the rupture of an intracranial aneurysm must be suspected in spontaneous subdural hematomas, especially in association with disproportioned conscious deterioration. All the three patients we report debuted with sudden conscious deterioration. If a ruptured aneurysm causing subdural hematoma is suspected, early surgical intervention is required even if angiography is not available. Severe neurological deficit and uncal herniation might still be reversible if provided decompression can be carried out in promptly. Angiography availability should not postpone surgery. Aneurysm presence should be ruled out whether by surgical exploration or by delayed angiography. Posterior communicating aneurysm are related to formation of subdural hematoma.