Utilidad de la ecografía en la punción retrógrada distal en la isquemia crítica de extremidades inferiores / Usefulness of ultrasound-guided tibio-pedal access in patients with critical limb ischemia

Introducción La punción retrógrada se puede realizar guiada mediante fluoroscopia o ecografía. Nuestro objetivo fue analizar la utilidad de la ecografía en la punción retrógrada distal de las extremidades inferiores. Métodos Estudio analítico observacional de diciembre del 2013 a junio del 2019. Se incluyeron todos los accesos retrógrados distales que fueron realizados guiados ecográficamente. Se analizaron datos demográficos y clínicos, vaso utilizado como acceso retrógrado, procedimiento efectuado, cantidad de contraste usada y tiempo de escopia, fallo en el acceso y complicaciones locales. Resultados De 715 procedimientos, se utilizó el acceso retrógrado ecoguiado en 25 pacientes (64% hombres). La edad media fue de 74,8 años (45 a 90), con un 92% de diabéticos y un 32% de insuficiencia renal crónica. La clínica inicial era estadio 4 de Rutherford en dos pacientes y estadios 5-6 en los restantes 23. En 24 (96%) pacientes la punción ecoguiada fue satisfactoria, mientras que en un caso (4%) no se consiguió entrar en el vaso diana. Posteriormente a la punción, el éxito técnico de la revascularización fue conseguido en 19 (79,2%) pacientes, con cinco (20,8%) en los que no se consiguió superar la lesión. Las arterias utilizadas como acceso retrógrado fueron: tibial anterior 11, tibial posterior 10 y peronea en cuatro. Se utilizó una media de 63mL (9 a 100 mL) de contraste con un tiempo medio de escopia de 43 minutos (15 a 76 min). No se observaron complicaciones relacionadas con el acceso retrógrado. Conclusiones El acceso retrógrado distal ecoguiado es un método seguro y efectivo, que supone un buen recurso en aquellos procedimientos endovasculares en los que no es posible su realización vía anterógrada (AU)

Introduction Retrograde access performed guided by fluoroscopy or ultrasound. We aimed to analyze the usefulness of ultrasound in retrograde access in patients with critical limb ischemia. Methods Observational analytical study. From December 2013 to June 2019. We included all retrograde accesses that were guided by ultrasound. Our register assesses demographic and clinical data, the vessel used as retrograde access, the procedure performed, the amount of contrast agent used and time of fluoroscopy, access failure, and local complications. Results On 715 procedures performed, was used ultrasound-guided retrograde access in 25 patients (64% men). The mean age was 74.8 years (45-90), with 92% of diabetics and 32% of chronic renal failure. Two patients with Rutherford stage 4 and 23 with stage 5-6. In 24 (96%) patients the ultrasound-guided puncture was successful, while in one (4%) of them, it was not possible to enter the target vessel. After the punch, was achieved the technical success of revascularization in 19 (79.2%) patients, with 5(20.8%) in whom did not the arterial injury was not overcome. The arteries used as retrograde access were: anterior tibial 11, posterior tibial 10, and peroneal in 4. The mean of contrast used was 63 mL (9-100 ml) with an average time of 43 minutes (15- 76 min). Complications related did not observe in retrograde access. Conclusions Ultrasound- guided retrograde distal access is an effective method that may use as a bailout method in those endovascular procedures in which it is not possible to cross the lesion anterogradely (AU)

Response to azacitidine in patients with chronic myelomonocytic leukemia according to overlap myelodysplastic/myeloproliferative neoplasms criteria.

BACKGROUND: Azacitidine (AZA) is approved for the treatment of high-risk chronic myelomonocytic leukemia (CMML) of myelodysplastic (MD) subtype. Data of response rates using the specific response criteria for this disease are scarce. The aim of this study was to evaluate the response to AZA in patients diagnosed with CMML from the Spanish Registry of Myelodysplastic Syndromes (MDS) applying the overlap myelodysplastic/myeloproliferative neoplasms (MDS/MPN) response criteria. METHODS: We retrospectively studied 91 patients with CMML treated with at least one cycle of AZA from the Spanish Registry of MDS. As it was a real-world study, the response rate was evaluated between cycle 4 and 6, applying the MDS/MPN response criteria FINDINGS: The overall response rate at cycle 4-6 was 58%. Almost half of the patients achieved transfusion independence and one quarter showed clinical benefit, regardless of the CMML French-American-British (FAB) and World Health Organization (WHO) subtypes and CMML Specific Prognosis Scoring (CPSS) risk groups. Toxicity was higher in the MD-CMML subtype. INTERPRETATION: In our series, most CMML patients achieved an overall response rate with AZA according to the overlap-MDS/MPN response criteria regardless of the CMML FAB and WHO subtypes and CPSS risk groups. Thus, AZA may also be a treatment option for patients with the myeloproliferative CMML subtype and those with a lower-risk CPSS, but symptomatic.

Different methylation signatures at diagnosis in patients with high-risk myelodysplastic syndromes and secondary acute myeloid leukemia predict azacitidine response and longer survival.

BACKGROUND: Epigenetic therapy, using hypomethylating agents (HMA), is known to be effective in the treatment of high-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) patients who are not suitable for intensive chemotherapy and/or allogeneic stem cell transplantation. However, response rates to HMA are low and there is an unmet need in finding prognostic and predictive biomarkers of treatment response and overall survival. We performed global methylation analysis of 75 patients with high-risk MDS and secondary AML who were included in CETLAM SMD-09 protocol, in which patients received HMA or intensive treatment according to age, comorbidities and cytogenetic. RESULTS: Unsupervised analysis of global methylation pattern at diagnosis did not allow patients to be differentiated according to the cytological subtype, cytogenetic groups, treatment response or patient outcome. However, after a supervised analysis we found a methylation signature defined by 200 probes, which allowed differentiating between patients responding and non-responding to azacitidine (AZA) treatment and a different methylation pattern also defined by 200 probes that allowed to differentiate patients according to their survival. On studying follow-up samples, we confirmed that AZA decreases global DNA methylation, but in our cohort the degree of methylation decrease did not correlate with the type of response. The methylation signature detected at diagnosis was not useful in treated samples to distinguish patients who were going to relapse or progress. CONCLUSIONS: Our findings suggest that in a subset of specific CpGs, altered DNA methylation patterns at diagnosis may be useful as a biomarker for predicting AZA response and survival.

Evidence against a role for NLRP3-driven islet inflammation in db/db mice.

OBJECTIVES: Type 2 diabetes (T2D) is associated with chronic, low grade inflammation. Activation of the NLRP3 inflammasome and secretion of its target interleukin-1ß (IL-1ß) have been implicated in pancreatic ß cell failure in T2D. Specific targeting of the NLRP3 inflammasome to prevent pancreatic ß cell death could allow for selective T2D treatment without compromising all IL-1ß-associated immune responses. We hypothesized that treating a mouse model of T2D with MCC950, a compound that specifically inhibits NLRP3, would prevent pancreatic ß cell death, thereby preventing the onset of T2D. METHODS: Diabetic db/db mice were treated with MCC950 via drinking water for 8 weeks from 6 to 14 weeks of age, a period over which they developed pancreatic ß cell failure. We assessed metabolic parameters such as body composition, glucose tolerance, or insulin secretion over the course of the intervention. RESULTS: MCC950 was a potent inhibitor of NLRP3-induced IL-1ß in vitro and was detected at high levels in the plasma of treated db/db mice. Treatment of pre-diabetic db/db mice with MCC950, however, did not prevent pancreatic dysfunction and full onset of the T2D pathology. When examining the NLRP3 pathway in the pancreas of db/db mice, we could not detect an activation of this pathway nor increased levels of its target IL-1ß. CONCLUSIONS: NLRP3 driven-pancreatic IL-1ß inflammation does not play a key role in the pathogenesis of the db/db murine model of T2D.

Beneficios del ácido acetilsalicílico en la recurrencia de trombosis venosa profunda de miembros inferiores en pacientes mayores de 70 años / Benefits of acetylsalicylic acid in the recurrence of deep vein thrombosis of the lower limbs in patients over 70 years-old

Introducción: El riesgo de recurrencia, después de un episodio de trombosis venosa profunda, está entre el 7-20% en los 2 años posteriores a la retirada de la anticoagulación. El objetivo de este trabajo es valorar el papel del ácido acetilsalicílico (AAS) en la recurrencia de trombosis venosa profunda, una vez finalizado el tratamiento anticoagulante en pacientes de 70 años o mayores, en nuestra población. Material y métodos: Se realizó un estudio retrospectivo de casos y controles de pacientes que presentaron un primer episodio de trombosis venosa profunda de miembros inferiores, confirmado por ecografía-Doppler, durante el período de enero de 2008 hasta diciembre de 2009. Se valoró, mediante revisión de historias clínicas, la presencia de recidiva en los 3 años siguientes al tratamiento anticoagulante mediante los controles en consultas externas, y la presencia o no de tratamiento con AAS por cualquier enfermedad de base. Resultados: Incluimos en el estudio un total de 246 pacientes con una media de edad de 78,7 años. Se dividieron los pacientes en 2 grupos, el grupo A (n = 106) formado por pacientes que tomaban AAS por cualquier enfermedad de base; y el grupo B (n = 140) formado por pacientes que no tomaban AAS. Se observó recidiva de trombosis venosa profunda en 28 pacientes del estudio (11,5%), registrándose 13 en el grupo A (12,3%) y 15 en el grupo B (10,7%), sin observarse diferencias estadísticamente significativas (p = 0,70). Conclusiones: En nuestra población mayor de 70 años, el tratamiento con AAS no parece disminuir la tasa de recidivas de trombosis venosa profunda (AU)

Introduction: The risk of recurrence after an episode of deep vein thrombosis is between 7% and 20% in the 2 years after withdrawal of anticoagulants. The main objective of this article is to study the role of acetylsalicylic acid in the recurrence of deep vein thrombosis once the anticoagulation treatment has ended in patients of 70 years-old and over. Material and methods: A retrospective study was conducted on patients that presented with a first episode of lower limb deep vein thrombosis confirmed by Doppler-ultrasound between the period of January 2008 and December 2009. Their clinical charts were reviewed for the presence of recurrence in the three years following anticoagulation treatment whilst on outpatient follow-up, as well as whether they were on treatment with acetylsalicylic acid for any underlying disease. Results: The study included 246 patients, with a mean age of 78.7 years. The patients were divided into two groups: Group A (n = 106) consisted of patients who took acetylsalicylic acid; and Group B (n = 140) consisted of patients who did not take acetylsalicylic acid. Recurrence of deep vein thrombosis was observed in 28 patients (11.5%), 13 patients in Group A (12.3%) and 15 patients in Group B (10.7%), without observing any statistically significant differences (P = .70) Conclusions: In our population aged 70 years-old and over, it seems that the treatment with acetylsalicylic acid has no influence on deep vein thrombosis recurrence (AU)

Registro de actividades de la Sociedad Española de Angiología y Cirugía Vascular, año 2014 / Activities register of the Spanish Society of Angiology and Vascular Surgery: 2014

OBJETIVO: Describir la actividad asistencial del año 2014 de los servicios/unidades de Angiología y Cirugía Vascular en España. PACIENTES Y MÉTODOS: Estudio transversal con encuesta a 107 centros sobre procedimientos quirúrgicos y exploraciones vasculares realizados en 2014. Análisis descriptivo de resultados y comparación de la ratio de actividad/100.000 habitantes con 2013. RESULTADOS: Respondieron 72 servicios (35 de ellos, docentes) correspondientes a 78 centros. En 2014 se produjeron 44.295 ingresos, 32,2% urgentes y 67,8% programados, con estancia media de 7,3 días. En lista de espera, a 31/12/2014, existía predominio de la patología venosa sobre la arterial (13.446 vs. 1.890). La actividad quirúrgica global en cirugía arterial en 2014 fue semejante a la de 2013 con variaciones en la ratio/100.000 habitantes según el sector: 9,4 vs. 10,3 en troncos supraaórticos; 1,2 vs. 1,5 en aorta torácica; 0,38 vs. 0,31 en aorta toracoabdominal; 1,3 vs. 1,4 en arterias viscerales; 9,6 vs. 9,4 en aorta abdominal; 11,2 vs. 11,4 en sector aortoilíaco; 22,0 vs. 21,4 en sector femoropoplíteo y 9,9 vs. 9,4 en sector distal. Prácticamente en todas ellas la ratio de procedimientos de cirugía convencional fue inferior, mientras que el de cirugía endovascular aumentó en algunos. En 2014 se realizaron similar número de accesos de hemodiálisis (20,6 vs. 19,9). La actividad en amputaciones mayores y menores fue semejante (7,4 vs. 7,6 y 10,8 vs. 11,3). La actividad global en 2014 sobre el sector venoso fue semejante a la de 2013 (65,4 vs. 67,4), si bien se realizaron más procedimientos con cirugía endovascular para tratamiento de varices. La ratio/100.000 habitantes de exploraciones vasculares fue parecido a 2013 (760,5 vs. 764,1). CONCLUSIÓN: Con relación a 2013: se mantiene la participación y la actividad quirúrgica arterial global, con incremento de procedimientos endovasculares en algunos territorios; la venosa global se ha mantenido, con gran aumento de procedimientos endovasculares para el tratamiento de varices; las exploraciones vasculares se han mantenido

OBJECTIVE: To describe the health-care activities carried out by Angiology and Vascular Surgery Departments/Units in Spain in 2014. PATIENTS AND METHODS: Cross-sectional study using a questionnaire sent to 107 centres on surgical procedures and vascular examinations performed in 2014. A descriptive analysis of results and comparison of the activity ratio/100,000 population with 2013 is also presented. RESULTS: Responses were received from 72 department (35 of them teaching), corresponding to 78 centres. In 2014 there were 44,295 admissions, of which 32.2% were emergency and 67.8% were elective, with a mean hospital stay of 7.3 days. The waiting list on December, 31st 2014 showed a predominance of venous rather than arterial disease (13,446 vs. 1,890). Arterial surgery in 2014 was similar to 2013, with some differences in the ratios/100,000 population: 9.4 vs. 10.3 in the supra-aortic trunk, 1.2 vs. 1.5 in the thoracic aorta, 0.38 vs. 0.31 in the thoracic-abdominal aorta, 1.3 vs. 1.4 in visceral arteries, 9.9 vs. 9.4 in the abdominal aorta, 11.2 vs. 11.4 in the aortic-iliac segment, 22.0 vs. 21.4 in the femoral-popliteal segment, and 9.0 vs. 9.4 in the distal segment. The ratio of conventional surgical procedures was lower for all of these, whereas that of endovascular surgery increased in some cases. Compared to 2013, there was similar number of haemodialysis access procedures performed in 2014 (20.6 vs. 19.9). Procedures involving major and minor amputations were similar (7.4 vs. 7.6, 10.8 vs. 11.3, respectively). The overall venous surgery activity in 2014 was similar to 2013 (65.4 vs. 67.4), although there were more procedures using endovascular surgery. The ratio/100,000 population of vascular examinations was similar to 2013 (760.5 vs. 764.1). CONCLUSION: The activity was stable in 2014 compared to 2013, in almost the whole area of arterial surgery, although endovascular procedures increased in some vascular areas. Venous surgery on the whole has remained, with similar number of procedures, despite that the varicose treatments significantly increased in endovascular procedures. Vascular examinations maintained a similar activity to 2013

Questions and controversies in innate immune research: what is the physiological role of NLRP3?

The NLRP3 inflammasome is a key component of the innate immune system that induces pro-inflammatory cytokine production and cell death. Although NLRP3 is activated by many pathogens, it only appears to be critical for host defense for a limited number of specific infections. NLRP3 is however strongly associated with the initiation and pathology of many inflammatory diseases. If NLRP3 function is largely redundant for host defense, but drives a number of inflammatory diseases, this raises the important question of why evolution has elected to maintain NLRP3 function. We propose that the primary physiological functions of NLRP3 in health are to engage pathways to clear noxious substances (e.g. protein aggregates and crystals), and to regulate metabolism. We discuss the newly identified functions for NLRP3 in metabolic homeostasis, and how NLRP3 beneficial functions in homeostasis may become detrimental during the onset of inflammatory and metabolic diseases. A common feature of most NLRP3-driven diseases is that they are associated with ageing or metabolic excess, and indeed, Nlrp3 deficiency promotes 'healthspan' in ageing mice. This suggests that beneficial functions of NLRP3 in youth may become increasingly countered by NLRP3-dependent pathology as an individual ages, and we propose a general model by which ageing or nutrient excess may provide a tipping point to switch NLRP3 function from beneficial to pathological. The physiological role of NLRP3 in healthy individuals remains incompletely understood and future research will need to address this if NLRP3 is to become a successful therapeutic target for the clinical management of inflammatory diseases.

Registro de actividades de la Sociedad Española de Angiología y Cirugía Vascular, año 2013 / Activities register of the Spanish Angiology and Vascular Surgery Society in 2013

OBJETIVO: Describir la actividad asistencial del año 2013 de los Servicios/Unidades de Angiología y Cirugía Vascular en España. PACIENTES Y MÉTODOS: Estudio transversal con encuesta a 92 centros sobre procedimientos quirúrgicos y exploraciones vasculares realizados en 2013. Análisis descriptivo de resultados y comparación del ratio de actividad/100.000 habitantes con 2012. RESULTADOS: Respondieron 69 servicios (34 docentes), correspondientes a 75 centros. En 2013 se produjeron 49.206 ingresos, 36,8% urgentes y 63,2% programados, con estancia media de 7,2 días. En lista de espera, a 31/12/2013, existía predominio de afecció venosa sobre la arterial (12.410 vs. 2.199). La actividad quirúrgica en cirugía arterial en 2013 fue inferior a la de 2012 con los siguientes ratios/100.000 habitantes: 10,3 vs. 12,1 en troncos supraaórticos; 1,5 vs. 1,4 en aorta torácica; 0,31 vs. 0,33 en aorta toracoabdominal; 1,4 vs. 1,9 en arterias viscerales; 9,4 vs. 9,7 en aorta abdominal; 11,4 vs. 23,1 en sector aortoilíaco; 21,4 vs. 20,9 en sector femoropoplíteo y 9,4 vs. 13,7 en sector distal. En todas ellas, el ratio de procedimientos de cirugía convencional fue inferior, mientras que el de cirugía endovascular aumentó en algunos. En 2013 se realizaron menos accesos de hemodiálisis (19,9 vs. 24,0). La actividad en amputaciones mayores, menores y desbridamientos de pie diabético fue semejante (7,6 vs. 7,3; 11,3 vs. 11,4 y 5,6 vs. 5,6, respectivamente). La actividad en 2013 sobre varices fue igual a la de 2012 (ambas con ratio/100.000 habitantes = 66,1), si bien se realizaron más procedimientos con cirugía convencional y menos con endovascular. El ratio/100.000 habitantes de exploraciones vasculares fue superior en 2013 (764,1 vs. 697,8). CONCLUSIÓN: Con relación a 2012: ha disminuido la participación y la actividad quirúrgica arterial global, con incremento de procedimientos endovasculares en algunos territorios; la venosa global se ha mantenido, mientras que han disminuido los procedimientos endovasculares; las exploraciones vasculares han aumentado

OBJECTIVE: To describe the health-care activities carried out by the Services/Units of Angiology and Vascular Surgery in Spain in 2013. PATIENTS AND METHODS: Cross-sectional study with a survey of 92 centres on surgical procedures and vascular examinations performed in 2013. Descriptive analysis was performed on the results and a comparison was made on the ratio of activity/100,000 population with 2012. RESULTS: Responses were received from 69 services (34 teaching services), corresponding to 75 centres. In 2013 there were 49,206 admissions, of which 36.8% were emergencies and 63.2% were elective, with a mean stay of 7.2 days. As of 31 December 2013, the waiting list showed a predominance of venous over arterial pathology (12,410 vs. 2,199). Arterial surgery in 2013 was lower than in 2012, with the following ratios/100,000 population: 10.3 vs. 12.1 in the supra-aortic trunk, 1.5 vs. 1.4 in the thoracic aorta, 0.31 vs. 0.33 in the thoracic-abdominal aorta, 1.4 vs. 1.9 in visceral arteries, 9.4 vs. 9.7 in the abdominal aorta, 11.4 vs. 23.1 in the aorto-iliac segment, 21.4 vs. 20.9 in the femoro-popliteal segment, and 9.4 vs. 13.7 in the distal segment. For all of these, the ratio of conventional surgical procedures was lower, whereas that of endovascular surgery increased in some cases. In 2013 fewer haemodialysis access procedures were performed (19.9 vs. 24.0). Procedures involving major and minor amputations and diabetic foot debridement were similar (7.6 vs. 7.3, 11.3 vs. 11.4 and 5.6 vs. 5.6, respectively). Varicose vein procedures in 2013 were the same as in 2012 (both with a ratio of 66.1/100,000 population), although there were more procedures using conventional surgery and fewer with endovascular surgery. The ratio/100,000 population of vascular examinations was higher in 2013 (764.1 vs. 697.8). Conclusion : As compared to 2012, arterial surgery has decreased overall, and endovascular procedures have increased in some areas. Overall, venous surgery has remained the same, with a reduction in endovascular procedures. Vascular examinations have increased

Actualización de la Guía para el diagnóstico no invasivo de la insuficiencia venosa (II). Documento de consenso del capítulo de diagnóstico vascular de la Sociedad Española de Angiología y Cirugía Vascular / Update of the guidelines for the non-invasive diagnosis of venous insufficiency (II). Consensus document of the vascular diagnosis chapter of the Sociedad Española de Angiología y Cirugía Vascular

A pesar de que muchos estudios han pretendido cuantificar la insuficiencia venosa, tanto con eco-doppler como particularmente con pletismografía, en la práctica diaria sigue valorándose la insuficiencia venosa como presente o ausente. Una cuantificación simple como el diámetro safeniano que parece correlacionarse con el grado de insuficiencia venosa según publicación del servicio de cirugía vascular de Oviedo, se empieza a imponer como un parámetro de adquisición simple y reproducible. Esta segunda parte del documento de consenso de la insuficiencia venosa se centra en la insuficiencia venosa crónica, y en su diagnóstico con eco-doppler. Se repasan las maniobras de exploración remarcando la diferente información que puede aportar cada una. Se divide la información de la exploración en una parte anatómica y en otra hemodinámica. Finalmente, se hace un repaso actualizado de los diferentes tipos de shunts veno-venosos, cuyo desarrollo constituye un obstáculo para el fraccionamiento de la columna de sangre al caminar (defecto de fraccionamiento dinámico de la presión hidrostática)

Although many studies have tried to quantify venous insufficiency using either doppler ultrasound, and particularly with plethysmography, venous insufficiency continues to be evaluated as present or absent in daily practice. A simple quantification such as the diameter of the saphenous vein, which appears to correlate with the venous insufficiency grade (according to publication by the Oviedo Vascular Surgery Department), is starting to become a simple and reproducible parameter. This second part of the venous insufficiency consensus document focuses on chronic venous insufficiency and its diagnosis with doppler ultrasound. The investigation techniques are reviewed, commenting on the different information that each one of them can provide. The information from the exploration technique is divided into an anatomy part and a hemodynamic part. Finally, a current review is presented on the different types of veno-venous shunt, which prevents the fractionation of the blood column on walking (dynamic fractionating of the hydrostatic pressure column deficiency)

Actualización de la guía para el diagnóstico no invasivo de la insuficiencia ven osa (I). Documento de consenso del capítulo de diagnóstico vascular de la Sociedad Española de Angiología y Cirugía Vascular / Update of the guidelines for the non-invasive diagnosis of venous insufficiency (I). Consensus document of the vascular diagnosis chapter of the Sociedad Española de Angiología y Cirugía Vascular

Han pasado 12 años desde la publicación del primer documento de consenso para el diagnóstico de la insuficiencia venosa. Durante estos años, la herramienta diagnóstica que ha seguido ganando protagonismo en nuestros laboratorios es el eco-doppler. La actualización de esta guía no desmonta los conceptos básicos ya documentados en la primera guía, sino que ahonda en los relacionados con el eco-doppler. Este documento ha sido dividido en 2 partes debido a su extensión. Esta primera parte, tras una introducción en la que se repasa el concepto de insuficiencia venosa y su exploración con el equipamiento disponible en nuestros laboratorios, se centra en el diagnóstico de la trombosis venosa profunda mediante el eco-doppler. La notable mejoría técnica de los equipos, tanto en imagen modo B como en sensibilidad del doppler color, hacen que sea una exploración altamente fiable aun en las venas profundas distales

It has been 12 years since the publication of the first consensus document on the diagnosis of venous insufficiency. During these years, the diagnostic tool that has increasingly been used in our laboratories is ddoppler ultrasound. The updating of these guidelines does not replace the basic concepts, but goes into depth of those associated with ddoppler ultrasound. This document has been divided into 2 parts, due to its length. This first part, after an introduction that reviews the concept of venous insufficiency and its investigation with the equipment available in our laboratories, deals with the diagnosis of deep venous thrombosis using ddoppler ultrasound. The notable technical improvement of the equipment, both in B-mode image as well as the sensitivity of colour ddoppler, have led to very reliable investigations even in distal deep veins

Información de eventos adversos a pacientes y familiares / Adverse events open disclosure to patients and relatives

Objetivo: Realizar un revisión bibliográfica sobre la información de incidentes y eventos adversos a pacientes y familiares, así como revisar las principales políticas, guías institucionales y aspectos legales relacionados con dicho proceso. Material y método: Se consultaron diferentes fuentes electrónicas y en papel y se utilizó Pub-med como motor de búsqueda principal. Resultados: El sistema sanitario debe buscar la manera de cubrir las necesidades y expectativas de los pacientes cuando ocurre un evento adverso a través del cuidado, soporte emocional e información relativa al evento. Las guías éticas y profesionales establecen la responsabilidad de los profesionales y de las instituciones de desvelar los errores cometidos durante la atención sanitaria. Existen muchas barreras que dificultan llevar a cabo este complejo proceso. La formación de los profesionales y el desarrollo de guías institucionales pueden favorecer el cumplimiento. Los aspectos legales deben ser abordados a nivel local y evaluar el impacto real de un desarrollo legislativo específico sobre la efectividad del proceso. Conclusión: En nuestro ámbito no existen recomendaciones específicas en relación a la información a pacientes y familiares sobre eventos adversos. Se requieren propuestas consensuadas que den respuesta de forma científica y multidisciplinar a esta cuestión con importantes connotaciones tanto éticas como legales (AU)

Objective: Perform a literature review on incidents and adverse events open disclosure to patients and relatives, as well as to review major policies, institutional guides and legal aspects related to this process. Material and method: Different electronic and paper sources were consulted; Pub-med was used as main search engine. Results: The health system must find a way of meeting the needs and expectations of patients, emotional support and information on the event when an adverse event occurs through care. Ethical and professional guidelines set out the professionals and institutions responsibility of revealing the mistakes made during the health care. There are many barriers that make it difficult to carry out this complex process. The training of professionals and the development of institutional guides can encourage compliance. The legal aspects should be dealt with at local level and to assess the real impact of a specific legislative development on the effectiveness of the process. Conclusion: In our area, there are no specific recommendations in relation to the adverse event information to patients and relatives. Required consensus proposals that respond in a scientific and multidisciplinary manner to this question with important connotations both ethical and legal (AU)

Conferencia de consenso sobre información de eventos adversos a pacientes y familiares / Consensus conference on providing information of adverse events to patients and relatives

Objetivo. Elaborar unas recomendaciones sobre «Información de eventos adversos a pacientes y familiares», mediante la realización de una conferencia de consenso. Material y métodos. Se realizó una revisión bibliográfica de la evidencia disponible, de las principales publicaciones de políticas y guías internacionales y la legislación específica desarrollada en algunos países sobre dicho proceso. La revisión bibliográfica constituyó la base para dar respuesta a una serie de preguntas planteadas en una sesión pública. Un grupo de expertos presentaron la mejor evidencia disponible interaccionando con las partes interesadas. Al término de la sesión un jurado, interdisciplinario y multiprofesional, estableció las recomendaciones finales de la conferencia de consenso. Resultados. Las principales recomendaciones abogan por el interés de elaborar políticas y guías institucionales en nuestro ámbito que favorezcan el proceso de información sobre eventos adversos a los pacientes. Se destaca la necesidad de formación de los profesionales en habilidades de comunicación y en seguridad del paciente, así como el desarrollo de estrategias de soporte a los profesionales que se ven implicados en un evento adverso. Se considera evaluar el interés e impacto de legislación específica que ayudará a la implantación de dichas políticas. Conclusiones. Es necesario un cambio cultural a todos los niveles, matizado y adaptado a las circunstancias específicas sociales y culturales de nuestro ámbito social y sanitario, e implicar a todos los actores del sistema para crear un marco de confianza y credibilidad en el que pueda hacerse efectivo el proceso de información sobre eventos adversos (AU)

Objective: To develop recommendations regarding «Information about adverse events to patients and their families», through the implementation of a consensus conference. Material and methods: A literature review was conducted to identify all relevant articles, the major policies and international guidelines, and the specific legislation developed in some countries on this process. The literature review was the basis for responding to a series of questions posed in a public session. A group of experts presented the best available evidence, interacting with stakeholders. At the end of the session, an interdisciplinary and multi-professional jury established the final recommendations of the consensus conference. Results: The main recommendations advocate the need to develop policies and institutional guidelines in our field, favouring the patient adverse events disclosure process. The recommendations emphasize the need for the training of professionals in communication skills and patient safety, as well as the development of strategies for supporting professionals who are involved in an adverse event. The assessment of the interest and impact of specific legislation that would help the implementation of these policies was also considered. Conclusions: A cultural change is needed at all levels, nuanced and adapted to the specific social and cultural aspects of our social and health spheres, and involves all stakeholders in the system to create a framework of trust and credibility in which the processing of information about adverse events may become effective (AU)

[Consensus conference on providing information of adverse events to patients and relatives]. / Conferencia de consenso sobre información de eventos adversos a pacientes y familiares.

OBJECTIVE: To develop recommendations regarding «Information about adverse events to patients and their families¼, through the implementation of a consensus conference. MATERIAL AND METHODS: A literature review was conducted to identify all relevant articles, the major policies and international guidelines, and the specific legislation developed in some countries on this process. The literature review was the basis for responding to a series of questions posed in a public session. A group of experts presented the best available evidence, interacting with stakeholders. At the end of the session, an interdisciplinary and multi-professional jury established the final recommendations of the consensus conference. RESULTS: The main recommendations advocate the need to develop policies and institutional guidelines in our field, favouring the patient adverse events disclosure process. The recommendations emphasize the need for the training of professionals in communication skills and patient safety, as well as the development of strategies for supporting professionals who are involved in an adverse event. The assessment of the interest and impact of specific legislation that would help the implementation of these policies was also considered. CONCLUSIONS: A cultural change is needed at all levels, nuanced and adapted to the specific social and cultural aspects of our social and health spheres, and involves all stakeholders in the system to create a framework of trust and credibility in which the processing of information about adverse events may become effective.

Utilidad de los marcadores tumorales como cribado de neoplasia oculta en enfermedad tromboembólica / Role of tumour markers for occult neoplasia screening in thromboembolic disease

Objetivo: Evaluar la eficacia de los marcadores tumorales (MT) dentro del cribado avanzado para la detección de neoplasia oculta, en pacientes que han presentado enfermedad tromboembólica (ETE). Material y métodos: Estudio retrospectivo entre enero 2007 y diciembre de 2008 diagnosticados de ETE en nuestro centro. Se evaluaron los siguientes marcadores tumorales: antígeno carcinoso 19.9 (Ca 19.9), antígeno carcinoso 125 (Ca 125), antígeno carcinoso 15.3 (Ca 15.3), antígeno carcinoma embrionario (CEA), alfafetoproteína(AFP) y antígeno específico de próstata (PSA), tomando una determinación dentro del mes siguiente del diagnóstico de ETE. Criterios de inclusión: TVP de MMSS o MMII, TEP diagnosticados por prueba de imagen, clínica aguda. Criterios de exclusión: neoplasia previa conocida, TVP no idiopática, imposibilidad de seguimiento. Resultados: El 63,4% eran hombres, el 36,6% mujeres, con edad media de 62,8 años. El análisis estadístico se hizo en función de 122 pacientes, de los 199 iniciales, con un seguimiento medio de 38 meses. Al finalizar el estudio no se encontraron diferencias significativas en cuanto a la incidencia posterior de neoplasia respecto a los pacientes con valores de MT positivos de los negativos (Ca 125: p=0,161; Ca 15.3: p=0,930; CEA: p=0,703; PSA: p=0,382; AFP: 100% pacientes con valores negativos). Exceptuando el Ca 19.9 (p<0,000). Conclusiones: Como conclusión a nuestro estudio, el uso de MT como cribado de cáncer oculto posterior a un evento trombótico, no ha permitido la detección de los pacientes que desarrollaron una neoplasia durante el seguimiento (AU)

Objective: To evaluate the use of the tumour markers (TM) as part the advanced screening of occult neoplasia, in patients with thromboembolic disease (TED). Material and methods: A retrospective study was conducted between January 2007 and December 2008 on patients diagnosed with TED in our centre. The sample included 63.4% males, and 36.6% females, with a mean age of 62.8 years. The following TM were evaluated in a blood sample taken within one month after the diagnosis of TED: cancer antigen 19.9 (Ca 19.9), cancer antigen 125 (Ca 125), cancer antigen 15.3 (Ca 15.3), embryonic carcinoma antigen (CEA), alpha fetoprotein (AFP), and prostate specific antigen (PSA). The inclusion criteria were, DVT of lower and upper limbs, TEP diagnosed by imaging technique, acute clinic signs. Exclusion criteria: previous known neoplasia, non-idiopathic DVT, impossibility of follow-up. Results: The statistical analysis was performed on the basis of 122 patients out of 199 initially included, with an average follow-up of 38 months. At the end of the study no significant differences were found as regards the subsequent finding of a neoplasia in patients with positive TM values compared with those with negative values (Ca 125: P=0.161; Ca 15.3: P=0.930; CEA: P=0.703; PSA: P=0.382; AFP: 100% patients with negative values). Exempting the Ca 19.9 (P<0.000). Conclusions: As a conclusion of our study, TM as extensive screening of early stages of cancer after TED, is not useful for detecting an occult neoplasia during follow-up (AU)

Fenómeno de Raynaud y betabloqueantes en rehabiltación cardíaca / Raynaud's phenomenon and beta blockers in cardiac rehabilitation

No disponible

Tratamiento endovascular del aneurisma de aorta abdominal / Endovascular treatment of the abdominal aortic aneurysm

La publicación de la primera reparación endovascular de un aneurisma de aorta abdominal ha cumplido 20 años, y los estudios aleatorizados que comparan la cirugía abierta con la endovascular han completado los 10 años de seguimiento.La experiencia en la reparación endovascular ha crecido notablemente, así como su uso ampliado a anatomías complejas mediante endoprótesis estándar en unos casos o con fenestradas y/o ramificadas en otros. El empleo para aneurismas rotos se ha difundido, aunque su uso sistemático para ello cuenta aún con dificultades y diversos puntos de controversia que motivan estudios no aceptados por todos. Las novedades en nuevas endoprótesis son continuas, y actualmente asistimos a un boom de ofertas comerciales, frente a un reducido grupo establecido en el mercado desde hace años que, no obstante, también ha implementado modificaciones que deben demostrar su efectividad a largo plazo. Sociedades científicas internacionales destacadas en el ámbito europeo y mundial han publicado actualizaciones de sus guías entre 2010 e inicios de 2011, en un intento de plasmar la actualidad de un campo tan cambiante.En este momento parece razonable poner al día el documento publicado en el capítulo de Cirugía Endovascular de la Sociedad Española de Angiología y Cirugía Vascular (SEACV), que pretende ser un documento de base que, manteniendo la esencia del original, incorpora novedades, puntos de debate y propuestas razonadas de mejora a partir de las que establecer un acuerdo global en la reparación endovascular de AAA, tanto en aspectos clínicos como técnicos.Por ello las recomendaciones son genéricas, a falta de un consenso explícito y recomendaciones oficiales emanadas de la sociedad científica que nos agrupa(AU)

It is now twenty years since the publication of the first endovascular repair of an abdominal aortic aneurysm, and randomised studies comparing open surgery with endovascular surgery have completed 10 years of follow-up.Experience in endovascular repair has markedly increased, as well its widened use in complex anatomies using standard endoprosthesis in some cases, or fenestrated and/or branched in others. The use for ruptured aneurysms has spread, although its systematic use still for this still has difficulties and several points of controversy due to studies not accepted by everyone. The innovations in new stents are continuous, and we are currently experiencing a boom in commercial offer, due to a reduced group established in the market for years. These, however, have also implemented changes that still are to show their effectiveness in the long term. International scientific groups in Europe and worldwide have published updates of their guidelines between 2010 and the beginning of 2011, in an attempt to reflect the current situation in such a changing field.Up to this point, it seems reasonable to update the document published by the Endovascular Chapter of the Spanish Angiology and Vascular Surgery (SEACV), which attempts to be a reference document, that while maintaining the essence of the original, includes innovations, points for debate and reasoned proposals for improvement, from which to establish an overall agreement on the repair of abdominal aortic aneurysms, in both the clinical and technical aspects.For this reason the recommendations are generic, lack a clear consensus and official recommendations by the Scientific Society to which we belong(AU)

Estado actual de la educación para la salud en los programas de rehabilitación respiratoria / Current status of health education in the respiratory rehabilitation programs

Objetivo. La educación para la salud debe ser un componente básico de los programas de rehabilitación pulmonar (PRP). Sin embargo, un gran número de programas no contemplan su inclusión. Por otro lado, cuando la educación está presente, su estructura no es homogénea. Por este motivo, el objetivo de esta revisión es conocer cuál es el estado actual de la educación para la salud en pacientes afectos de enfermedades respiratorias. Resultados. En los últimos años, se han introducido cambios sustanciales en la estructura de los programas educativos para pacientes neumológicos. Dichos cambios han contemplado la aplicación de programas educativos basados en el autocuidado. Estas intervenciones van dirigidas a que el paciente aprenda las necesidades para cumplir con las pautas médicas e introducir comportamientos para controlar la enfermedad y el estado general. Aunque la contribución específica de la educación no se conoce con exactitud, diversos estudios muestran una tendencia a la reducción de los días de hospitalización y a un menor uso de los recursos sanitarios(AU)

Objective. Health education should be a core component of pulmonary rehabilitation programs (PRP). However, many programs do not consider the inclusion of education. On the other hand, when education is present, its structure is not homogeneous. The objective of this review is to know what the current status of education is for patients with respiratory diseases. Results. In recent years, substantial changes have been made in the structure of educational programs for patients with pulmonary diseases. These changes have seen the implementation of educational programs based on self-care. These interventions are aimed at having the patient learn what needs must be complied with including the medical guidelines and to introduce behaviors to control the disease and general condition. Although the specific contribution of education is not precisely known, several studies show a tendency to reduction in days of hospitalization and less use of the health resources(AU)

Guía de seguimiento no invasivo del tratamiento endovascular del aneurisma de aorta abdominal / Guidelines for the non-invasive follow-up of abdominal aortic aneurysm treatment

El tratamiento endovascular del aneurisma de aorta abdominal (EVAR) representa uno de los grandes avances de la cirugía vascular en los últimos 50 años. A diferencia del tratamiento abierto, el EVAR precisa un seguimiento postoperatorio estricto. Durante el seguimiento, la imagen del dispositivo y del aneurisma son de extrema importancia para identificar pacientes en riesgo que precisan una intervención secundaria. Ello ha conducido a protocolos de seguimiento rigurosos basados en estudios con angio-TC. El empleo de estos protocolos de seguimiento tan intensivos son criticados actualmente tanto por la alta radiación administrada al paciente como por el empleo de medios de contraste nefrotóxicos. Los programas de seguimiento postoperatorios menos intensivos y basados en ultrasonidos parecen ser seguros en la mayoría de los pacientes. Proponemos un régimen de seguimiento postoperatorio del EVAR que varía la intensidad y frecuencia de los estudios de imagen postoperatorios en función de los hallazgos(AU)

Endovascular aneurysm repair (EVAR) is one of the greatest advances in vascular surgery over the past 50 years. In contrast to conventional aneurysm repair, EVAR requires stringent posoperative surveillance. Imaging of the graft and aneurysm is of utmost importance during follow-up to identify patients in need of secondary intervention. This has led to rigorous follow-up protocols based on regular CT examinations. The use of these intense follow-up protocols has recently been questioned due to the high radiation doses and the frequent use of nephrotoxic contrast agents. Less intensive follow-up based on ultrasound examination appears to be safe in the vast majority of patients. We suggest an EVAR surveillance regimen that regulates the frequency and intensity of postoperative imaging based on the outcomes(AU)