Long-term outcomes of colonic stent as a "bridge to surgery"for left-sided malignant large-bowel obstruction.

BACKGROUND: The role of self-expandable metallic stents (SEMS) as a bridge to surgery in left-sided malignant colonic obstruction is still debated. Here we assess the morbidity, mortality and long-term oncological outcomes as a bridge to surgery for patients with left-sided malignant colonic obstruction. METHOD: Prospective observational study with retrospective analysis of patients with left-sided malignant colonic obstruction undergoing stenting. April 2006-April 2018. We assessed all patients with intent-to treat and per protocol analyses and long-term follow-up variables. RESULTS: Colonic stent was performed in 117 patients. Technical and clinical success of SEMS placement: 94.4% (111/117), only 4.3% perforation. Elective surgery resection following the strategy of SEMS was performed in 83.8% (98/117). A laparoscopic approach was: 25.6% (30/117); 76.9% in the last two years. Primary anastomosis rate: 92.8% (91/98), without protective stoma in any patients. Anastomotic leakage rate: 8.2% (8/97). Median follow-up: 44.5 months (range 0-109). The intent-to-treat analysis showed overall and disease-free survival rates of 63.3% (74/117) and 58.1% (68/117), and local and distant recurrence rates: 9.4% (11/117) and 58.1% (68/117). In the per protocol analysis, overall and disease-free survival rates: 63.2% (62/98) and 60.2% (58/98), and local and distant recurrence rates: 10.2% (10/98) and 36.7% (36/98). Disease progression was predominantly observed during the first 5 years' follow-up as disease recurrence; after five years' follow-up, 60% of the patients were disease-free. CONCLUSIONS: According to the results of the study SEMS as a bridge to surgery achieves perioperative results comparable to non-occlusive colonic cancer surgery and does not adversely affect long-term oncological outcomes. Further investigations are needed.

Preoperative giant sacrococcygeal teratoma embolization in a newborn - A case report and a review. / Embolización preoperatoria de teratoma sacrococcigéo gigante en un recién nacido. Reporte de un caso y revisión.

Sacrococcygeal teratoma (SCT) is the most frequent congenital germ cell tumor. Patients have a higher risk of perinatal complications and death, with bleeding and cardiac decompensation being the most common causes of neonatal mortality. This is the case of a 35-week preterm newborn with a large SCT diagnosed at ultrasound screening in the second trimester. Preoperative selective embolization of the middle sacral artery and total surgical resection were performed postnatally with minimal blood loss. The patient was discharged at 25 days of life with a normal physical examination. Selective embolization prior to giant SCT resection is feasible and appears as a safe and useful technique in the control of perioperative bleeding.

El teratoma sacrococcígeo (TSC) es el tumor congénito de células germinales más frecuente. Los pacientes afectados tienen un mayor riesgo de complicaciones perinatales y muerte, siendo la hemorragia y la descompensación cardiaca las causas más comunes de mortalidad neonatal. Presentamos el caso de un recién nacido pretérmino de 35 semanas con un TSC de gran tamaño diagnosticado por ecografía en el segundo trimestre. La embolización selectiva preoperatoria de la arteria sacra media y la resección quirúrgica total postnatal se realizaron con una mínima pérdida de sangre. El paciente fue dado de alta a los 25 días de vida con un examen físico normal. La embolización selectiva antes de la cirugía de resección del TSC gigante es factible y aparece como una técnica segura y útil en el control del sangrado perioperatorio.

Embolización preoperatoria de teratoma sacrococcígeo gigante en un recién nacido. Reporte de un caso y revisión / Preoperative giant sacrococcygeal teratoma embolization in a newborn - A case report and a review

El teratoma sacrococcígeo (TSC) es el tumor congénito de células germinales más frecuente. Los pacientes afectados tienen un mayor riesgo de complicaciones perinatales y muerte, siendo la hemorragia y la descompensación cardiaca las causas más comunes de mortalidad neonatal. Presentamos el caso de un recién nacido pretérmino de 35 semanas con un TSC de gran tamaño diagnosticado por ecografía en el segundo trimestre. La embolización selectiva preoperatoria de la arteria sacra media y la resección quirúrgica total postnatal se realizaron con una mínima pérdida de sangre. El paciente fue dado de alta a los 25 días de vida con un examen físico normal. La embolización selectiva antes de la cirugía de resección del TSC gigante es factible y aparece como una técnica segura y útil en el control del sangrado perioperatorio

Sacrococcygeal teratoma (SCT) is the most frequent congenital germ cell tumor. Patients have a higher risk of perinatal complications and death, with bleeding and cardiac decompensation being the most common causes of neonatal mortality.This is the case of a 35-week preterm newborn with a large SCT diagnosed at ultrasound screening in the second trimester. Preoperative selective embolization of the middle sacral artery and total surgical resection were performed postnatally with minimal blood loss. The patient was discharged at 25 days of life with a normal physical examination. Selective embolization prior to giant SCT resection is feasible and appears as a safe and useful technique in the control of perioperative bleeding

Ablación percutánea mediante radiofrecuencia de tumores renales en pacientes de alto riesgo: 10 años de experiencia / Percutaneous radiofrequency ablation of renal tumors in high-risk patients: 10 years’ experience

Objetivo. Evaluar retrospectivamente la eficacia y la seguridad de la radiofrecuencia (RF) percutánea para el tratamiento de tumores renales en pacientes de alto riesgo o con riesgo de padecer tumores renales múltiples con un seguimiento a medio plazo a lo largo de un periodo de 10 años. Material y métodos. Entre 2005 y 2015, 87 pacientes (89 tumores) con una media de edad de 73,7 años (desviación estándar: 10,87) con riesgo quirúrgico alto que presentaban tumores renales T1a y T1b fueron tratados mediante RF. Se excluyeron los pacientes sometidos a RF y embolización o ablación con microondas. Se trataron carcinomas de células claras (43,6%), papilares (17,2%), cromófobos (10,3%), tumores quísticos (2,2%) y un angiomiolipoma (1,1%). El tamaño medio de los tumores fue 2,6cm. La tomografía computarizada y/o la ecografía se utilizaron para guiar el procedimiento. Se analizó la relación entre la eficacia y la edad de los pacientes, el tipo de aguja, el origen de los pacientes, el tamaño y localización tumoral, y el número de sesiones necesarias para ablacionar el tumor. Se registraron las complicaciones. Resultados. La RF se pudo realizar a todos los pacientes. La media de seguimiento fue de 32,1 meses. La eficacia fue de un 93,7%. El 87,5% de los pacientes requirieron una sola sesión, el 8%, 2 sesiones y el 4,5%, 3 sesiones. El único factor asociado a una menor eficacia fue el tamaño del tumor (p=0,03). La tasa de complicaciones fue del 5,6%. Conclusiones. La RF es eficaz y segura, con resultados comparables a los referidos en la literatura especializada (AU)

Objective. To retrospectively evaluate the efficacy and safety of percutaneous radiofrequency ablation (RFA) done to treat renal tumors in patients with high surgical risk or with the risk of developing multiple renal tumors in the medium term at our center over a period of 10 years. Material and methods. Between 2005 and 2015, we used RFA to treat 89 T1a or T1b tumors in 87 patients (mean age, 73.7±10.87 years) with high surgical risk. We excluded patients treated with radiofrequency and embolization or microwave ablation. The tumors treated were clear cell carcinomas (43.6%), papillary renal carcinomas (17.2%), chromophobe renal cell carcinomas (10.3%), cystic tumors (2.2%), and an angiomyolipoma (1.1%). The mean size of the tumors was 2.6cm. Computed tomography and/or ultrasonography were used to guide the procedure. We analyzed the relation between the efficacy of the procedure and patients’ age, the type of needle, the source of the patients, the size and location of the tumor, and the number of sessions required to achieve ablation. We recorded all complications. Results. The RFA procedure was completed in all patients. The mean follow-up period was 32.1 months. The efficacy was 93.7%. A single session was sufficient in 87.5% of patients; 8% required two sessions and 4.5% required three sessions. The only factor associated with worse efficacy was the size of the tumor (p=0.03). The rate of complications was 5.6%. Conclusions. RFA is efficacious and safe, with results comparable to those reported in the literature (AU)

Percutaneous radiofrequency ablation of renal tumors in high-risk patients: 10 years' experience. / Ablación percutánea mediante radiofrecuencia de tumores renales en pacientes de alto riesgo: 10 años de experiencia.

OBJECTIVE: To retrospectively evaluate the efficacy and safety of percutaneous radiofrequency ablation (RFA) done to treat renal tumors in patients with high surgical risk or with the risk of developing multiple renal tumors in the medium term at our center over a period of 10 years. MATERIAL AND METHODS: Between 2005 and 2015, we used RFA to treat 89 T1a or T1b tumors in 87 patients (mean age, 73.7±10.87 years) with high surgical risk. We excluded patients treated with radiofrequency and embolization or microwave ablation. The tumors treated were clear cell carcinomas (43.6%), papillary renal carcinomas (17.2%), chromophobe renal cell carcinomas (10.3%), cystic tumors (2.2%), and an angiomyolipoma (1.1%). The mean size of the tumors was 2.6cm. Computed tomography and/or ultrasonography were used to guide the procedure. We analyzed the relation between the efficacy of the procedure and patients' age, the type of needle, the source of the patients, the size and location of the tumor, and the number of sessions required to achieve ablation. We recorded all complications. RESULTS: The RFA procedure was completed in all patients. The mean follow-up period was 32.1 months. The efficacy was 93.7%. A single session was sufficient in 87.5% of patients; 8% required two sessions and 4.5% required three sessions. The only factor associated with worse efficacy was the size of the tumor (p=0.03). The rate of complications was 5.6%. CONCLUSIONS: RFA is efficacious and safe, with results comparable to those reported in the literature.

Pulsioximetría frente al monitor de electrocardiograma para la determinación de la frecuencia cardíaca durante la reanimación del recién nacido pretérmino / Pulse oximetry versus electrocardiogram for heart rate assessment during resuscitation of the preterm infant

INTRODUCCIÓN: La medición de frecuencia cardíaca (FC) es esencial durante la reanimación neonatal y se realiza habitualmente mediante auscultación o pulsioximetría (PO). El objetivo de este estudio es analizar si durante la reanimación del recién nacido prematuro la medición de la FC mediante ECG es tan precoz y fiable como la PO. MATERIAL Y MÉTODOS: Se realizó video-grabación de la reanimación de 39 recién nacidos prematuros (<32 semanas o <1.500g), registrando medidas de FC simultáneamente mediante ECG y PO cada 5 s desde el nacimiento hasta los 10 min de vida. Se determinó el tiempo necesario para colocación, obtención de lectura fiable y pérdida de señal de ambos dispositivos, así como la proporción de medida fiable de FC al inicio de cada maniobra de reanimación. RESULTADOS: El tiempo de colocación fue menor en ECG que en PO (17,10±1,28 s vs. 26,64±3,01 s; p < 0,05). Igualmente, el tiempo desde el fin de la colocación hasta la obtención de una lectura fiable fue menor para ECG que para PO (26,38±3,41 s vs. 87,28±12,11 s; p < 0,05). La proporción de medidas fiables de la FC al inicio de la reanimación fue menor en PO (PO vs. ECG para ventilación con presión positiva: 10,52 vs. 57,89%; p < 0,05; intubación: 33,33 vs. 91,66%; p < 0,05). La PO subestimó la FC con medidas inferiores a las del ECG durante los primeros 6 min de vida (p < 0,05 entre los 150 y 300 s). CONCLUSIONES: En la reanimación del prematuro la obtención de la FC fiable es más tardía con la PO que con ECG; además, la PO subestima la FC en los primeros momentos de la reanimación

BACKGROUND: Heart rate (HR) assessment is essential during neonatal resuscitation, and it is usually done by auscultation or pulse oximetry (PO). The aim of the present study was to determine whether HR assessment with ECG is as fast and reliable as PO during preterm resuscitation. MATERIAL AND METHODS: Thirty-nine preterm (<32 weeks of gestational age and/or<1.500g of birth weight) newborn resuscitations were video-recorded. Simultaneous determinations of HR using ECG and PO were registered every 5s for the first 10min after birth. Time needed to place both devices and to obtain reliable readings, as well as total time of signal loss was registered. The proportion of reliable HR readings available at the beginning of different resuscitation manoeuvres was also determined. RESULTS: Time needed to connect the ECG was shorter compared with the PO (26.64±3.01 vs. 17.10±1.28 s, for PO and ECG, respectively, P<.05). Similarly, time to obtain reliable readings was shorter for the ECG (87.28±12.11 vs. 26.38±3.41 s, for PO and ECG, respectively,P<.05). Availability of reliable HR readings at initiation of different resuscitation manoeuvres was lower with the PO (PO vs. ECG for positive pressure ventilation: 10.52 vs. 57.89% P<.05; intubation: 33.33 vs. 91.66%, P<.05). PO displayed lower HR values during the first 6min after birth (P<.05, between 150 and 300s). CONCLUSIONS: Reliable HR is obtained later with the PO than with the ECG during preterm resuscitation. PO underestimates HR in the first minutes of resuscitation

[Pulse oximetry versus electrocardiogram for heart rate assessment during resuscitation of the preterm infant]. / Pulsioximetría frente al monitor de electrocardiograma para la determinación de la frecuencia cardíaca durante la reanimación del recién nacido pretérmino.

BACKGROUND: Heart rate (HR) assessment is essential during neonatal resuscitation, and it is usually done by auscultation or pulse oximetry (PO). The aim of the present study was to determine whether HR assessment with ECG is as fast and reliable as PO during preterm resuscitation. MATERIAL AND METHODS: Thirty-nine preterm (<32 weeks of gestational age and/or<1.500g of birth weight) newborn resuscitations were video-recorded. Simultaneous determinations of HR using ECG and PO were registered every 5s for the first 10min after birth. Time needed to place both devices and to obtain reliable readings, as well as total time of signal loss was registered. The proportion of reliable HR readings available at the beginning of different resuscitation manoeuvres was also determined. RESULTS: Time needed to connect the ECG was shorter compared with the PO (26.64±3.01 vs. 17.10±1.28 s, for PO and ECG, respectively, P<.05). Similarly, time to obtain reliable readings was shorter for the ECG (87.28±12.11 vs. 26.38±3.41 s, for PO and ECG, respectively, P<.05). Availability of reliable HR readings at initiation of different resuscitation manoeuvres was lower with the PO (PO vs. ECG for positive pressure ventilation: 10.52 vs. 57.89% P<.05; intubation: 33.33 vs. 91.66%, P<.05). PO displayed lower HR values during the first 6min after birth (P<.05, between 150 and 300s). CONCLUSIONS: Reliable HR is obtained later with the PO than with the ECG during preterm resuscitation. PO underestimates HR in the first minutes of resuscitation.

Effect of periodontal dressing on non-surgical periodontal treatment outcomes: a systematic review.

BACKGROUND: Periodontal dressing has been advocated and showed some positive outcomes for placing over the surgical site after periodontal surgery. However, little is known about its effect on non-surgical therapy. PURPOSE: The aim of this review was to assess the clinical effect of periodontal dressing when used after non-surgical therapy. MATERIAL AND METHODS: Two examiners performed an electronic search in several databases for relevant articles published in English up to November 2013. Selected studies were randomized human clinical trials (prospective or retrospective trials) with the clear aim of investigating the effect of periodontal dressing placement upon periodontal non-surgical mechanical therapy. Data were extracted from the included articles for analysis. RESULTS: Three randomized clinical trials fulfilled the inclusion criteria and thus were included in the data analysis. Statistical analysis could not be carried out due to the lack of clear data of the included studies. However, descriptive analysis showed its effectiveness in improving clinical parameters such as gain of clinical attachment level and reduction of probing pocket depth. CONCLUSION: Placement of periodontal dressing right after non-surgical mechanical therapy can be beneficial in improving overall short-term clinical outcomes, although more controlled studies are still needed to validate this finding.

Distrofia simpático-refleja y mioclonías: una asociación infrecuente / Complex regional pain syndrome and myoclonus: an uncommon combination

La distrofia simpático-refleja es una patología infrecuente en la edad pediátrica, que no se relaciona con un trastorno orgánico subyacente y que requiere un tratamiento multidisciplinar debido al importante componente psicosomático que lo acompaña y al difícil control de los síntomas en este cuadro. Por otro lado, las mioclonías tienen un amplio espectro de diagnósticos diferenciales, siendo muy importante descartar enfermedades neurológicas y degenerativas subyacentes. Presentamos el caso de un varón adolescente con dolor neuropático en una localización atípica y con una presentación compleja al asociar mioclonías y distonías a lo largo de su evolución, que obliga a la revisión de ambos cuadros y a realizar un amplio diagnóstico diferencial (AU)

Complex regional pain syndrome (CRPS) is quite uncommon in paediatric patients.There is no identified organic aetiology. CRPS has a very significant psychosomatic component; therefore it is necessary to take a multidisciplinary approach to its treatment, which should include psychiatric assessment. CRPS is very difficult to diagnose, and can take months to control its symptoms. The association with myoclonus is rare, and since myoclonus is the clinical manifestation of a vast spectrum of different neurological disorders, some of which are degenerative, it is important to make a diagnosis as quickly as possible.We present the case of an adolescent male with an atypical presentation of CRPS. CRPS was located in the thorax, which is very unusual and was associated with myoclonus and dystonias.This made the diagnosis harder and widened the aetiological spectrum (AU)

[Complex regional pain syndrome and myoclonus: an uncommon combination]. / Distrofia simpático-refleja y mioclonías: una asociación infrecuente.

Complex regional pain syndrome (CRPS) is quite uncommon in paediatric patients. There is no identified organic aetiology. CRPS has a very significant psychosomatic component; therefore it is necessary to take a multidisciplinary approach to its treatment, which should include psychiatric assessment. CRPS is very difficult to diagnose, and can take months to control its symptoms. The association with myoclonus is rare, and since myoclonus is the clinical manifestation of a vast spectrum of different neurological disorders, some of which are degenerative, it is important to make a diagnosis as quickly as possible. We present the case of an adolescent male with an atypical presentation of CRPS. CRPS was located in the thorax, which is very unusual and was associated with myoclonus and dystonias. This made the diagnosis harder and widened the aetiological spectrum.

Hiponatremia secundaria a oxcarbazepina / Oxcarbazepine-induced hyponatremia

La utilización de la oxcarbazepina como tratamiento anticomicial se ha relacionado con numerosos casos de hiponatremia (sodio [Na] sérico <135mmol/l), tanto en monoterapia como en combinación con diuréticos u otros fármacos. Los mecanismos etiopatogénicos son variados y las causas más promulgadas son la liberación inadecuada y/o una mayor sensibilidad de la vasopresina tubular, así como el incremento de agua y la pérdida secundaria de Na. Presentamos un caso de una mujer de 67 años con una hiponatremia secundaria (Na sérico <120mmol/l) a oxcarbazepina con un cuadro clínico sintomático de hiponatremia que mejoró notablemente ante su retirada y sustitución por levetiracetam. Hacemos una revisión de los casos publicados al respecto, valorando el fármaco, las interacciones y los tratamientos concomitantes. Concluimos haciendo notar la importancia de diferenciar estos cuadros de los etiquetados como «asténicos o depresivos propios de la edad» cuando evaluemos a pacientes geriátricos en atención primaria (AU)

The use of oxcarbazepine as anti-seizure treatments has been related with many cases of hyponatremia (serum sodium <135mmol/l) both in single drug therapy as well as in combination with diuretics or other drugs. The etiopathogenic mechanisms are varied, inadequate release and/or greater sensitivity of tubular vasopressin as well as increased water and secondary loss of sodium being the most expressed one. We present a case of a 67-year old woman with hyponatremia secondary (serum sodium < 120mmol/l) to oxcarbazepine with a symptomatic clinical picture of hyponatremia that significantly improved when it was discontinued and replaced by levetiracetam. We have made a review of the cases published on this, evaluating the drug, interactions and concomitant treatments. We conclude by making note of the importance of differentiating these pictures from those labeled as "asthenic or depressive subjects characteristic of the age" when we evaluate geriatric patients in Primary Health Care (AU)

A prospective evaluation of cerebral infarction following transcervical carotid stenting with carotid flow reversal.

OBJECTIVE: Cerebral embolisation constitutes the main source of complications during transfemoral carotid artery stenting (CAS) and is associated with a high incidence of silent brain infarction. The goal of this study is to evaluate the incidence of new ischaemic cerebral lesions following transcervical CAS with carotid flow reversal for neuroprotection. MATERIALS AND METHODS: Thirty-one consecutive patients underwent transcervical CAS with carotid flow reversal. A stroke scale and diffusion-weighted magnetic resonance imaging (DW-MRI) were performed within 24 h before and after the procedure. DW-MRI studies were compared blindly by two independent neuroradiologists. New hyper-intense DW signals were interpreted as ischaemic infarcts. The progress of all patients was followed for at least 30 days following intervention. RESULTS: All procedures were technically successful. Nineteen (61%) patients were symptomatic Mean carotid flow reversal time was 22 min. There were no major adverse events at 30 days. All patients remained neurologically intact without increase in the stroke scale. Thirty subjects had paired DW-MRI studies. Post-procedural DW-MRI ischaemic infarcts were found in four (12.5%) patients, all ipsilateral to the treated hemisphere and asymptomatic. During follow-up, all stents remained patent and all patients remained stroke-free. CONCLUSIONS: These data suggest that transcervical carotid stenting with carotid flow reversal carries a low incidence of new ischaemic infarcts, significantly lower than that reported with transfemoral CAS. The transcervical approach with carotid flow reversal may improve the safety of CAS and has the potential to produce results comparable to those of carotid endarterectomy.

Transcervical carotid artery stenting with flow reversal eliminates emboli during stenting: why does it work and what are the advantages with this approach.

Carotid artery stenting (CAS) remains under scrutiny because of the controversial results of major trials that compared it with carotid endarterectomy. However, the question of how the results of carotid stenting are influenced by the access technique and cerebral protection methods has not been properly addressed in any trial. Most unresolved technical weaknesses of transfemoral carotid stenting are related to instrumentation of the arch and proximal supra-aortic trunks, crossing of the carotid lesion without protection, and use of distal filter protection devices of unproven benefit. All these problems can be avoided by using a transcervical approach with carotid flow reversal for protection. The potential advantage of transcervical carotid artery stenting (CAS) is demonstrated by the fact that it can be done in octogenarians without increased morbidity, produces a lower incidence of middle cerebral artery transcranial Doppler (TCD)-detected embolic signals during the procedure, carries a significant reduction in the incidence of ischemic brain infarcts as detected by diffusion weighted magnetic resonance imaging (MRI), when compared to transfemoral stenting with distal filter protection, and can be done with a remarkably low incidence of major adverse events.

Manejo de una vía aérea difícil en el medio prehospitalario / No disponible

El manejo óptimo de la vía aérea y ventilación de pacientes críticos sigue siendo un pilar básico en la supervivencia, evolución y pronóstico; la intubación orotraqueal (IOT) es el gold standard en estas situaciones. Conocer la posición, lasmaniobras y el material “facilitador” de la IOT, así como realizar una oxigenación-ventilación previa y una sedorrelajación adecuadas, aumentará de forma significativa las posibilidades de éxito.Hay ocasiones en las que, aun siendo ortodoxos en la realización de la técnica, no conseguimos el fin deseado (no intubación, no ventilación), definiéndose tal situación como vía aérea difícil (VAD). Los médicos y enfermeros de Atención Primaria deben estar preparados ante tal eventualidad y disponer del material y la formación necesarios para hacer frente a este momento crítico en el manejo de pacientes graves.Basándonos en las directrices y guía clínicas de las principales sociedades científicas en el manejo de la vía aérea (Grupo Español para el Manejo de la Vía Aérea [GEMVA], Sociedad Americana de Anestesiología [ASA] y el Colegio Americano de Cirujanos), presentamos una revisión de las alternativas recomendadas, centrándonos en una somera descripción del material y una más amplia exposición de la técnica

Optimum management of the airway and ventilation incritical patients continues to be a basic cornerstone in survival, evolution and prognosis. orotracheal intubation (OTI) is the “gold standard” in these situations. Knowing the position, maneuvers and material that “facilitate” the OTI and how to perform previous adequate oxygen-ventilation and sedoanalgesia will significantly increase the possibilities ofsuccess.There are times when, although being orthodox in thetechnique performance, we do not achieve the desired purpose (no intubation, no ventilation), defining such a situation as difficult airway (DAW). Primary Health Care physicians and nurses should be prepared for this and have the necessary material and training to face this critical moment in the management of severe patients.Taking the clinical guidelines of the principal scientific societies into account in the management of the airway (Spanish Group for the Management of the Airway [GEMVA], American Society of Anesthesiology [ASA], and the American College of Surgeons), we present a review of the alternatives recommended, focusing on a brief description of the material and a more extensive presentation of the technique

Advantages and indications of transcervical carotid artery stenting with carotid flow reversal.

AIM: The aim of this Italian prospective registry was to evaluate the applicability and efficacy of the Mo.Ma Device (Invatec, Roncadelle, Italy) for the prevention of cerebral embolization during carotid artery stenting (CAS) in a real world population. METHODS: In 4 Italian centers, 416 patients (300 men; mean age 71.6+/-9 years) between October 2001 and March 2005 were enrolled in a prospective registry. Two-hundred and sixty-four symptomatic (63.46%) with >50% diameter stenosis and 152 (36.54%) asymptomatic patients with >70% diameter stenosis were included. The Mo.Ma Proximal Flow Blockage Embolic Protection System was used to perform protected CAS, achieving cerebral protection by endovascular clamping of the common carotid artery (CCA) and of the external carotid artery (ECA). RESULTS: Technical success, defined as the ability to establish protection with the Mo.Ma device and to deploy the stent, was achieved in 412 cases (99.03%). The mean duration of flow blockage was 4.91+/-1.1 min. Transient intolerances to flow blockage were observed in 24 patients (5.76%), but in all cases the procedure was successfully completed. No peri-procedural strokes and deaths were observed. Complications during hospitalization included 16 minor strokes (3.84%), 3 transient ischemic attacks (0.72%), 2 deaths (0.48%) and 1 major stroke (0.24%). This resulted in a cumulative rate at discharge of 4.56% all strokes and deaths, and of 0.72% major strokes and deaths. All the patients underwent thirty-day follow-up. At thirty-day follow-up, there were no deaths and no minor and major strokes, confirming the overall cumulative 4.56% incidence of all strokes and deaths rate, and of 0.72% rate of major strokes and deaths at follow up. In 245 cases (58.89%) there was macroscopic evidence of debris after filtration of the aspirated blood. CONCLUSIONS: This Italian multicenter registry confirms and further supports the efficacy and applicability of the endovascular clamping concept with proximal flow blockage in a broad patient series. Results match favorably with current available studies on carotid stenting with cerebral protection.

[Medullar carcinoma of the thyroid gland: surgical treatment of mediastinal metastases]. / Carcinoma medular de tiroides: tratamiento quirúrgico de metástasis mediastínica.

Metastatic medullary carcinoma is related to very bad prognosis. Surgery, associated or not to radiotherapy, may be effective in controlling metastasis due to local invasion, as in mediastinal extension. We present a case of medullary carcinoma with mediastinal disease that was treated through mediastinal dissection following by complimentary radiotherapy. After three years of follow-up, the patient remains free of recurrence, although calcitonin levels have not become normal yet.

Carcinoma medular de tiroides: tratamiento quirúrgico de metástasis mediastínica / Medullar carcinoma of the thyroid gland: surgical treatment of mediastinal metastases

Las metástasis del carcinoma medular de tiroides comportan muy mal pronóstico. LA cirugía, asociada o no a radioterapia, puede ser efectiva en el control de las metástasis por invasión local, como en los ganglios mediastínicos. Presentamos un caso de carcinoma medular de tiroides con extesión mediastínica, que fue tratado mediante vaciamiento ganglionar mediastínico por esternotomía media y radioterapia complementaria. Tras tres años de seguimiento, permanece sin recidiva, aunque los niveles de calcitonina no se han normalizado totalmente (AU)

Valoración global del enfermo hipertenso.Hiponatremia inducida por carbamazepinay diuréticos / Global evaluation of hypertensive patients. Hyponatremia induced by carbamazepine and diuretics

Presentamos el caso de una paciente de 70 años con antecedentes de hipertensión arterial (HTA), hipertrofia ventricular izquierda (HVI) electrocardiográfica y neuralgia del trigémino, con presiones arteriales (PA) controladas. En el último año tuvo varios cambios en su tratamiento hipotensor por elevaciones paulatinas de la PA. Acude a la consulta por astenia, intolerancia al esfuerzo, decaimiento, parestesias y calambres musculares de varios meses de evolución que iban progresivamente en aumento. Tras un estudio detallado se llega a la conclusión de que se trata de síntomas atribuibles a efectos secundarios de los bloqueadores beta, unido a una hiponatremia secundaria al consumo tanto de diuréticos como de carbamazepina. Igualmente se aprecia que el "supuesto buen control tensional", no era correcto y que tras una simple automedición de PA en domicilio (AMPA) con aparato automático validado se constató de forma mantenida una variabilidad tensional con aumentos constantes de PA por la mañana. Tras los cambios correspondientes de tratamiento y un seguimiento posterior se apreció la desaparición de los síntomas y normalización de sus alteraciones iónicas (AU)

Duplex scanning or arteriography for preoperative planning of lower limb revascularisation.

OBJECTIVE: to compare the accuracy of duplex and angiography for the planning of lower limb revascularisation. PATIENTS AND METHODS: Sixty limbs (82% with critical limb ischaemia) were assessed by means of duplex by one surgeon and by angiography by another in terms of the optimum inflow and outflow sites for arterial bypass. These data were then compared with the final operation performed which was used as the gold standard. Surgeons were blinded to the determinations of the other. RESULTS: surgical plans based on duplex scan and angiography were correct in 77% (40/52) and 79% (41/52), respectively and plans based on the one imaging modality was modified by the other in only 1 and 2 instances. The diagnostic agreement between duplex scanning and arteriography was excellent (Kappa value=0.94, 95% C.I. 0.89-0.98). CONCLUSIONS: the reliability of duplex scanning is comparable to digital angiography in the preoperative planning of lower extremity arterial reconstruction. However neither exam can be considered as the gold standard because intraoperative arteriography needs to be available in a significant number of infrapopliteal procedures.