Capi-score: a quantitative algorithm for identifying disease patterns in nailfold videocapillaroscopy.

OBJECTIVES: The European Alliance of Associations for Rheumatology (EULAR) supports the use of nailfold videocapillaroscopy (NVC) to identify disease patterns (DPs) associated with systemic sclerosis (SSc) and Raynaud's phenomenon (RP). Recently, EULAR proposed an easy-to-manage procedure, a so-called Fast Track algorithm, to differentiate SSc from non-SSc patterns in NVC specimens. However, subjectivity among capillaroscopists remains a limitation. Our aim was to perform a software-based analysis of NVC peculiarities in a cohort of samples from SSc and RP patients and, subsequently, build a Fast Track-inspired algorithm to identify DPs without the constraint of interobserver variability. METHODS: NVCs were examined by 9 capillaroscopists. Those NVCs whose DPs were consensually agreed (≥2 out of 3 interobservers) were subsequently analysed with an in-house developed software. Each variable's results were grouped according to the consensually agreed DPs in order to identify useful hallmarks to categorise them. RESULTS: Eight-hundred and fifty-one NVCs (21 957 images) whose DPs had been consensually agreed were software-analysed. Appropriate cut-offs set in capillary density and percentage of abnormal and giant capillaries, tortuosities and hemorrhages allowed DP categorization and the development of the CAPI-Score algorithm. This consisted of 4 rules: Rule 1, SSc vs non-SSc, accuracy 0.88; Rules 2 and 3, SSc-early vs SSc-active vs SSc-late, accuracy 0.82; Rule 4, non-SSc normal vs non-SSc non-specific, accuracy 0.73. Accuracy improved when the analysis was limited to NVCs whose DPs had achieved full consensus among interobservers. CONCLUSIONS: The CAPI-Score algorithm may become a useful tool to assign DPs by overcoming the limitations of subjectivity.

Immunoglobulins in systemic sclerosis management. A large multicenter experience.

OBJECTIVE: To analyze the effectiveness and safety of intravenous immunoglobulin (IVIG) given in routine care to patients with systemic sclerosis (SSc). METHODS: A retrospective multicenter observational study was conducted in SSc patients treated with IVIG. We collected data on epidemiological parameters and clinical outcomes. Firstly, we assessed changes in organ manifestations during IVIG treatment. Secondly, we analyzed the frequency of adverse effects. The following parameters were collected from baseline to the last follow-up: the patient's weight, modified Rodnan Skin Score (mRSS), modified manual muscle strength scale (MRC), laboratory test(creatine kinase(CK), hemoglobin and protein levels), The University of California Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 (UCLA GIT 2.0) questionnaire, pulmonary function tests, and echocardiography. RESULTS: Data were collected on 78 patients (82% females; 59% with diffuse SSc). Inflammatory idiopathic myopathy was the most frequent concomitant overlap disease (41%). The time since Raynaud's phenomenon and SSc onset were 8.8 ± 18 and 6.2 ± 6.7 years respectively. The most frequent IVIG indication was myositis (38/78), followed by gastrointestinal (27/78) and cutaneous (17/78) involvement. The median number of cycles given were 5. 54, 53 and 9 patients have been treated previously with glucocorticoids, synthetic disease-modifying antirheumatic drugs and biologic therapies respectively. After IVIG use we found significant improvements in muscular involvement (MRC ≥ 3/5 92% IVIG, p = 0.001 and CK levels from 1149 ± 2026 UI to 217 ± 224 UI, p = 0.02), mRSS (15 ± 12.4 to 13 ± 12.5, p = 0.015) and improvement in total score of UCLA GIT 2.0 (p = 0.05). None Anti-RNA polymerase III patients showed an adequate response in gastrointestinal involvement (0/7) in comparison with other antibodies (0 vs. 25, p = 0,039). Cardiorespiratory involvement remained stable. A total of 12 adverse events were reported with only one withdrawn due to serious adverse effect. CONCLUSIONS: this study suggest that IVIG may improve myositis, gastrointestinal and skin involvement in SSc patients treated in routine care and seems to have a good safety profile.

Systemic sclerosis associated myopathy: how to treat.

Purpose of review: Systemic sclerosis (SSc) and myositis are two different entities that may coexist as an overlap syndrome. Immunological biomarkers such as anti-PM/Scl or anti-Ku reinforce the syndrome. This review is focused on the treatment of different and characteristic manifestations of this syndrome. Recent findings: Among the different phenotypes of muscle involvement in patients with SSc, the fibrotic pattern and the sporadic inclusion body myositis must be identified early to avoid a futile immunosuppressive treatment. Other forms such as dermatomyositis, non-specific myositis and immune-mediated necrotizing myopathy need to receive conventional immunosuppressive therapy considering that high dose of glucocorticoids may induce a scleroderma renal crisis in patients with SSc. Physicians must be aware of the existence of a "double trouble" association of hereditary myopathy with an autoimmune phenomenon. Several autoantibodies, mainly anti-PM/Scl and anti-Ku may help to define specific phenotypes with characteristic clinical manifestations that need a more specific therapy. Vasculopathy is one of the underlying mechanisms that link SSc and myositis. Recent advances in this topic are reviewed. Summary: Current treatment of SSc associated myopathy must be tailored to specific organs involved. Identifying the specific clinical, pathological, and immunological phenotypes may help to take the correct therapeutic decisions.

Periodontitis and Cardiovascular Diseases. Consensus Report.

Background: In Europe cardiovascular disease (CVD) is responsible for 3.9 million deaths (45% of deaths), being ischaemic heart disease, stroke, hypertension (leading to heart failure) the major cause of these CVD related deaths. Periodontitis is also a chronic non-communicable disease (NCD) with a high prevalence, being severe periodontitis, affecting 11.2% of the world's population, the sixth most common human disease. Material and Methods: There is now a significant body of evidence to support independent associations between severe periodontitis and several NCDs, in particular CVD. In 2012 a joint workshop was held between the European Federation of Periodontology (EFP) and the American Academy of Periodontology to review the literature relating periodontitis and systemic diseases, including CVD. In the last five years important new scientific information has emerged providing important emerging evidence to support these associations. Results and Conclusions: The present review reports the proceedings of the workshop jointly organised by the EFP and the World Heart Federation (WHF), which has updated the existing epidemiological evidence for significant associations between periodontitis and CVD, the mechanistic links and the impact of periodontal therapy on cardiovascular and surrogate outcomes. This review has also focused on the potential risk and complications of periodontal therapy in patients on anti thrombotic therapy and has made recommendations for dentists, physicians and for patients visiting both the dental and medical practices.

Factores asociados con el delírium en pacientes críticos de una institución de salud de Bucaramanga, Colombia / Factors associated with delirium in critical patients in a health institution in Bucaramanga, Colombia

Objetivo: Determinar la incidencia y los factores asociados con delírium en pacientes de la Unidad de Cuidados Intensivos. Métodos: Se condujo un estudio de cohortes en 134 pacientes de la unidad de cuidados intensivos en una clínica de Bucaramanga, Colombia. Quienes fueron reclutados en las primeras 24 h de ingreso y se les aplicaron las escalas de sedación y agitación de Richmond (RASS), PRE-DELIRIC versión en español y Confusion Assessment Method for Intensive Care Unit (CAM-ICU); el desenlace se evaluó a través de seguimiento diario con CAM-ICU. Resultados: La incidencia de delírium fue del 20,2%, predominando el de tipo hipoactivo 66,7%, seguido del hiperactivo 7,4% y mixto 25,9%. El 52% de los pacientes con delírium fallecieron. En el análisis bivariado, se identificaron como factores de riesgo para delírium, el uso de sedantes (riesgo relativo [RR] 2,4, intervalo de confianza del 95% [IC del 95%] = 1,2-4,5), infección (RR = 2,8, IC del 95% = 1,3-5,9), acidosis metabólica (RR = 4,3, IC del 95% = 2,3-8), ventilación mecánica (RR = 4,6, IC del 95% = 2-10,6), edad mayor a 60 años (RR = 2,3, IC del 95% = 1,09-5,3) y puntaje APACHE mayor a 14 (RR = 3, IC del 95% = 1,1-8,2). En el análisis multivariado, solo se encontró relación con la infección (RR = 3,8, IC del 95% = 1,6-9,1) y la edad mayor a 60 años (RR = 3,2, IC del 95% = 1,2-8,3). Conclusiones: El delírium es frecuente en los pacientes de la Unidad de Cuidado Intensivo, en especial el hipoactivo. La mitad de los pacientes con delírium fallecieron. Los principales factores de riesgo para delírium son infección y la edad mayor a 60 años, por lo tanto, las actividades de prevención de delírium deben ser enfocadas a estos pacientes críticos

Objective: To determine the incidence and the factors associated with delirium in intensive care unit patients. Methods: A cohort study conducted on 134 patients in the intensive care unit at a clinic in Bucaramanga, Colombia., who were recruited in the first 24 hours following admission and on whom the Richmond Agitation-Sedation Scale (RASS), PRE-DELIRIC version in Spanish, and Confusion Assessment method for Intensive Care Unit (CAM-ICU) were applied; the outcome was evaluated through daily monitoring with CAM-ICU. Results: The incidence of delirium was 20.2%, the predominating type was hypoactive at 66.7%, followed by the hyperactive type at 7.4% and mixed at 25.9%. Fifty-two percent of the patients with delirium died. In the bivariate analysis, the use of sedatives (Relative Risk(RR) 2.4, 95% confidence interval (95% CI) = 1.2-4.5), infection (RR = 2. 8, 95% CI=1.3-5.9), metabolic acidosis (RR = 4 3, 95% CI=2.3-8.0), mechanical ventilation (RR = 4 6, 95% CI=2.0-10.6), aged over 60 years (RR = 2 3, 95% CI=1.09-5.3) and APACHE score greater than 14 (RR = 3. 0) (95% CI=1.1-8.2) were identified as risk factors for delirium. The multivariate analysis only found a relationship with infection (RR = 3 8, 95% CI=1.6-9.1) and being aged over 60 years (RR = 3 2, 95% CI 1.2-8.3). Conclusions: delirium is frequent in patients in the intensive care unit, especially the hypoactive type. Half of the patients with delirium died. The main risk factors for delirium are infection and being over 60 years age, therefore, delirium prevention activities should focus on these critical patients

Brain iron accumulation in a blood donor family with restless legs syndrome. / Aumento de los depositos cerebrales de hierro en una familia de donantes de sangre con sindrome de piernas inquietas.

INTRODUCTION: The pathophysiology of restless legs syndrome (RLS) is complex. Secondary RLS with iron deficiency -which suggests disturbed iron homeostasis- remains to be elucidated. CASE REPORTS: We report the findings from a unique blood donor family with RLS. Three blood donors family members were diagnosed with RLS defined by the International RLS Study Group and without history of neurologic diseases and RLS symptoms in the last 3-5 years (range of blood donation: 10-40 years). The neurological examination and electromyographies were normal. A polisomnography showed disturbed nocturnal sleep with a reduction in sleep efficiency and an increased periodic limbs movement index. The cranial MRI showed brain iron deposits in basal ganglia, substantia nigra, red nuclei and dentate nuclei. Phenotypic and genotypic studies rule out genetic haemochromatosis or iron overload. CONCLUSION: The abnormal iron accumulation in the basal ganglia indicated a complex iron metabolism disorder of the central nervous system. Further studies are warranted to confirm our findings and its role in the pathophysiology of RLS.

TITLE: Aumento de los depositos cerebrales de hierro en una familia de donantes de sangre con sindrome de piernas inquietas.Introduccion. La fisiopatologia del sindrome de piernas inquietas (SPI) es compleja. El mecanismo a traves del cual la ferropenia favorece el desarrollo del SPI no esta esclarecido, aunque se sugiere la presencia de una alteracion en la homeostasis cerebral del hierro. Casos clinicos. Se presentan los hallazgos inusuales en una familia de donantes de sangre con SPI. Tres miembros de la misma familia fueron diagnosticados de SPI, cumpliendo los criterios definidos por el grupo internacional para el estudio del SPI (International Restless Legs Syndrome Study Group). Todos eran donantes de sangre habituales (rango de donacion: 10-40 años) y los sintomas de SPI tenian un curso de 3-5 años. La exploracion general y neurologica fue normal en todos los casos, asi como los electromiogramas. El estudio fenotipico y genotipico descarto la presencia de hemocromatosis y otras causas geneticas de sobrecarga cerebral de hierro. Los estudios polisomnograficos mostraron sueño nocturno perturbado, con reduccion de su eficiencia, y un aumento del indice de movimientos periodicos de las piernas. La resonancia magnetica craneal evidencio un aumento de los depositos cerebrales de hierro en los ganglios basales, la sustancia negra, el nucleo rojo y los dentados. Conclusion. Este aumento patologico de los depositos cerebrales de hierro sugiere la presencia de un complejo trastorno del metabolismo cerebral del hierro en nuestros pacientes. Futuros estudios deben confirmar estos hallazgos y profundizar en el estudio de su relacion con la fisiopatologia del SPI.

Factors associated with delirium in critical patients in a health institution in Bucaramanga, Colombia. / Factores asociados con el delírium en pacientes críticos de una institución de salud de Bucaramanga, Colombia.

OBJECTIVE: To determine the incidence and the factors associated with delirium in intensive care unit patients. METHODS: A cohort study conducted on 134 patients in the intensive care unit at a clinic in Bucaramanga, Colombia., who were recruited in the first 24hours following admission and on whom the Richmond Agitation-Sedation Scale (RASS), PRE-DELIRIC version in Spanish, and Confusion Assessment method for Intensive Care Unit (CAM-ICU) were applied; the outcome was evaluated through daily monitoring with CAM-ICU. RESULTS: The incidence of delirium was 20.2%, the predominating type was hypoactive at 66.7%, followed by the hyperactive type at 7.4% and mixed at 25.9%. Fifty-two percent of the patients with delirium died. In the bivariate analysis, the use of sedatives (Relative Risk(RR) 2.4, 95% confidence interval (95% CI) = 1.2-4.5), infection (RR = 2. 8, 95% CI=1.3-5.9), metabolic acidosis (RR = 4 3, 95% CI=2.3-8.0), mechanical ventilation (RR = 4 6, 95% CI=2.0-10.6), aged over 60 years (RR = 2 3, 95% CI=1.09-5.3) and APACHE score greater than 14 (RR = 3. 0) (95% CI=1.1-8.2) were identified as risk factors for delirium. The multivariate analysis only found a relationship with infection (RR = 3 8, 95% CI=1.6-9.1) and being aged over 60 years (RR = 3 2, 95% CI 1.2-8.3). CONCLUSIONS: delirium is frequent in patients in the intensive care unit, especially the hypoactive type. Half of the patients with delirium died. The main risk factors for delirium are infection and being over 60 years age, therefore, delirium prevention activities should focus on these critical patients.

Subclinical cardiovascular disease and Systemic Sclerosis: A comparison between risk charts, quantification of coronary calcium and carotid ultrasonography.

BACKGROUND AND OBJECTIVES: Recently published population-based cohort studies have shown a high prevalence of cardiovascular disease in Systemic Sclerosis (SSc) patients. The aim of this study is to compare three different methods to measure cardiovascular risk in patients with scleroderma. METHODS: Forty-three SSc patients were included. A prospective study was performed for evaluation of cardiovascular risk and subclinical atheromatosis using 3 non-invasive methods: cardiovascular risk tables, carotid Doppler ultrasonography and quantification of coronary calcium by computerized tomography (CT). RESULTS: The cardiovascular risk charts for the Spanish population did not identify patients at high cardiovascular risk. Framingham-REGICOR identified 13 intermediate-risk patients. Twenty-two patients (51.2%) had plaques on carotid ultrasonography. We performed a ROC curve to identify the best cutoff point for the quantification of coronary artery calcium (CACscore), the value of CACscore > 28 AU (Agatston Units) had the highest sensitivity (73%) and specificity (81%) for the diagnosis of subclinical atheromatosis. In the multiple regression study, age and decreased HDL cholesterol levels were identified as independent factors for subclinical atherosclerotic disease. No disease-related factors were associated with increased subclinical arteriosclerosis. CONCLUSION: Carotid ultrasound and CACscore are useful for identifying subclinical atheromatosis in patients with SSc and are superior compared to risk charts used for general population. HDL cholesterol and age were independent factors for the presence of subclinical atherosclerotic disease. A carotid ultrasound or CT should be performed for early detection of subclinical atheromatosis if these factors are present.

Stability of anterior open bite treatment with bonded spurs associated with high-pull chincup.

OBJECTIVE: To evaluate the stability of anterior open bite (AOB) treatment with bonded spurs associated with high-pull chincup (BS/HPCC). METHODS: The experimental group consisted of 25 Class I AOB patients (15 female, 10 male) treated with BS/HPCC for 1 year. Cephalograms were analysed at pre-treatment (T1), post-treatment (T2) and at the 3-year post-treatment (T3) stage with the patients mean ages of 8.10, 9.14 and 12.18 years, respectively. The control group consisted of 23 subjects (13 female, 10 male) with normal occlusion, with comparable ages at the 3 stages (8.45, 9.45 and 12.50 years at T1, T2 and T3, respectively). T tests were used for intergroup comparisons at T1 and to compare the changes during the 3-year post-treatment period (T2-T3). Intragroup comparison in the treated group was evaluated with dependent t tests between T1 and T2. Correlations between the overbite changes in the T2-T3 period, the pre-treatment AOB severity and the amount of correction achieved during treatment were evaluated with Pearson's correlation coefficient. RESULTS: No statistically significant relapse of the AOB was found at T3. Only 1 patient had a clinically significant AOB relapse. Neither the pre-treatment AOB severity nor the amount of correction was related to overbite changes during the 3-year post-treatment period. CONCLUSIONS: There was no statistically significant relapse of the AOB, and the clinical stability of AOB correction 3-year post-treatment was of 96%.

First clinical symptom as a prognostic factor in systemic sclerosis: results of a retrospective nationwide cohort study.

The objective of the study is to determine the importance of the mode of onset as prognostic factor in systemic sclerosis (SSc). Data were collected from the Spanish Scleroderma Registry (RESCLE), a nationwide retrospective multicenter database created in 2006. As first symptom, we included Raynaud's phenomenon (RP), cutaneous sclerosis, arthralgia/arthritis, puffy hands, interstitial lung disease (ILD), pulmonary arterial hypertension (PAH), and digestive hypomotility. A total of 1625 patients were recruited. One thousand three hundred forty-two patients (83%) presented with RP as first symptom and 283 patients (17%) did not. Survival from first symptom in those patients with RP mode of onset was higher at any time than those with onset as non-Raynaud's phenomenon: 97 vs. 90% at 5 years, 93 vs. 82% at 10 years, 83 vs. 62% at 20 years, and 71 vs. 50% at 30 years (p < 0.001). In multivariate analysis, factors related to mortality were older age at onset, male gender, dcSSc subset, ILD, PAH, scleroderma renal crisis (SRC), heart involvement, and the mode of onset with non-Raynaud's phenomenon, especially in the form of puffy hands or pulmonary involvement. The mode of onset should be considered an independent prognostic factor in systemic sclerosis and, in particular, patients who initially present with non-Raynaud's phenomenon may be considered of poor prognosis.

Short-term and long-term effects of diazepam on the memory for discrimination and generalization of scopolamine.

Benzodiazepines are among the most widely prescribed and misused psychopharmaceutical drugs. Although they are well-tolerated, they are also capable of producing amnestic effects similar to those observed after pharmacological or organic cholinergic dysfunction. To date, the effect of benzodiazepine diazepam on the memory for discrimination of anticholinergic drugs has not been reported. The aim of the present study was to analyze the immediate and long-term effects of diazepam on a drug discrimination task with scopolamine. Male Wistar rats were trained to discriminate between scopolamine and saline administration using a two-lever discrimination task. Once discrimination was acquired, the subjects were divided into three independent groups, (1) control, (2) diazepam, and (3) diazepam chronic administration (10 days). Subsequently, generalization curves for scopolamine were obtained. Additionally, the diazepam and control groups were revaluated after 90 days without having been given any other treatment. The results showed that diazepam produced a significant reduction in the generalization gradient for scopolamine, indicating an impairment of discrimination. The negative effect of diazepam persisted even 90 days after drug had been administered. Meanwhile, the previous administration of diazepam for 10 days totally abated the generalization curve and the general performance of the subjects. The results suggest that diazepam affects memory for the stimulus discrimination of anticholinergic drugs and does so persistently, which could be an important consideration during the treatment of amnesic patients with benzodiazepines.

Patient doses and occupational exposure in a hybrid operating room.

PURPOSE: This study aimed to characterize the radiation exposure to patients and workers in a new vascular hybrid operating room during X-ray-guided procedures. METHODS: During one year, data from 260 interventions performed in a hybrid operating room equipped with a Siemens Artis Zeego angiography system were monitored. The patient doses were analysed using the following parameters: radiation time, kerma-area product, patient entrance reference point dose and peak skin dose. Staff radiation exposure and ambient dose equivalent were also measured using direct reading dosimeters and thermoluminescent dosimeters. RESULTS: The radiation time, kerma-area product, patient entrance reference point dose and peak skin dose were, on average, 19:15min, 67Gy·cm2, 0.41Gy and 0.23Gy, respectively. Although the contribution of the acquisition mode was smaller than 5% in terms of the radiation time, this mode accounted for more than 60% of the effective dose per patient. All of the worker dose measurements remained below the limits established by law. CONCLUSIONS: The working conditions in the hybrid operating room HOR are safe in terms of patient and staff radiation protection. Nevertheless, doses are highly dependent on the workload; thus, further research is necessary to evaluate any possible radiological deviation of the daily working conditions in the HOR.

Diagnosis and quantification of fibrosis, steatosis, and hepatic siderosis through multiparametric magnetic resonance imaging. / Diagnóstico y cuantificación de fibrosis, esteatosis y hepatosiderosis por medio de resonancia magnética multiparamétrica.

BACKGROUND: The presence of liver fibrosis is the common denominator in numerous chronic liver diseases that can progress to fibrosis and hepatocellular carcinoma. Most important, with respect to frequency, are viral hepatitis and non-alcoholic fatty liver disease, the prevalence of which is increasing in epidemic proportions. Liver biopsy, albeit imperfect, continues to be the criterion standard, but in many clinical situations tends to be replaced with noninvasive imaging methods. OBJECTIVES: The aim of the present article was to describe our imaging department experience with magnetic resonance elastography and to analyze and discuss recently published results in gastroenterology, hepatology, and radiology from other authors in the literature, complemented with a PubMed search covering the last 10 years. RESULTS AND CONCLUSIONS: Magnetic resonance elastography is an efficacious, noninvasive method with results that are concordant with liver biopsy. It is superior to ultrasound elastography because it evaluates a much greater volume of hepatic tissue and shows the often heterogeneous lesion distribution. The greatest advantage of the magnetic resonance protocol described is the fact that it quantifies fibrosis, fat content, and iron content in the same 25min examination specifically directed for that purpose, resulting in a favorable cost-benefit ratio for the patient and/or institution.

Comparación de resultados obtenidos en el tratamiento del dolor miofascial de la cintura pélvica con toxina botulínica sola y asociada con lidocaína / Comparison of results obtained in the treatment of the myofascial pain of the pelvic girdle with botulinum toxin alone and associated with lidocaine

Objetivos: entre el 70 y el 85 % de la población adulta sufre de dolor de espalda alguna vez en su vida. El síndrome de dolor miofascial (SDM) ha sido descrito recientemente definiéndose como dolor musculoesquelético no inflamatorio, localizado, desarrollado sin causa aparente, refractario a tratamientos farmacológicos y físicos, y se acompaña de la presencia de puntos gatillos y de bandas tensas palpables en el músculo. Su prevalencia se estima que varía entre un 30 y un 85 %. Los músculos psoas, cuadrado lumbar y piramidal son los más frecuentemente implicados en el SDM de cintura pélvica. Una de las principales alternativas para tratar el SDM es la toxina botulínica tipo A (TB), que actúa en la membrana sináptica en la placa neuromuscular, inhibiendo la liberación de acetilcolina, produciendo relajación muscular y alivio del dolor, aunque, en muchas ocasiones, su efecto no se hace evidente hasta transcurridos varios días. La lidocaína es un anestésico local (AL) tipo amida con duración de acción intermedia que actúa impidiendo la propagación del impulso nervioso disminuyendo la permeabilidad de los canales de sodio. El objetivo de este estudio era comprobar si al añadir AL a ladosis de TB, conseguíamos un acortamiento en el tiempo dela reducción de la EVA y mejoría de la calidad de vida. Material y métodos: el diseño del estudio fue prospectivo, controlado, longitudinal y aleatorizado en el que se ha valorado la evolución de 20 pacientes divididos en dos grupos. Al primer grupo se les administró TB tipo A (grupo T). Al segundo grupo se les trató con TB tipo A y dosis adicional de lidocaína al 2% (grupo TL). Previamente, ambos grupos, habían respondido de forma positiva a un test con infiltración del músculo afecto con lidocaína al 2 %. El seguimiento de los pacientes se hizo secuencialmente a los 3, 7, 15 y 90 días de iniciado el tratamiento. Para el análisis estadístico se utilizó un análisis de la varianza, ANOVA, complementada por la prueba de Mauchly para comprobación de la esfericidad y la prueba de Greenhouse-Geisser, con un intervalo de confianza del 95 %, considerando una p<0,05 para establecer diferencias estadísticas. Resultados: hubo diferencia estadísticamente significativa entre la EVA del grupo TL Y TB en la valoración a los tres días, del mismo modo en la evaluación del índice de Lattinen. No hubo diferencias significativas en el resto de valoraciones. En ambos grupos hubo diferencia significativa en la reducción del EVA y mejoría del índice de Lattinen, al principio y final del estudio. Conclusiones: la TXB-A presenta una alternativa al tratamiento de este cuadro cuando la terapia conservadora ha fracasado. Los anestésicos locales producen una relajación previsible, breve y reversible de la musculatura provocada por el bloqueo de la conducción nerviosa en las terminaciones nerviosas, mientras que la TXB actúa en las terminaciones neuronales de la placa motora, impidiendo la liberación de la acetil colina. Su acción la ejercen en lugares distintos y con características diferentes. La acción de los anestésicos locales es casi instantánea y breve, la de la TXB es diferida y duradera en el tiempo, por lo que pueden ser complementarias y agonistas en su efecto final

Objectives: between 70 and 85 % of the adult population suffers from back pain sometime in their life. Myofascial pain syndrome (MPS) has been described recently and defined as a localized non-inflammatory musculoskeletal pain, developed without apparent cause, being refractory to pharmacological and physical treatments, and is accompanied by the presence of trigger points and palpable taut bands in the muscle. Its prevalence is estimated to vary between 30 and 85 %. The psoas, quadratus lumborum and pyramidal muscles are the most frequently involved in the pelvic girdle MPS. One of the main alternatives to treat MPS is botulinum toxin type A (BT), which acts in the synaptic membrane at the neuromuscular junction, inhibiting the release of acetylcholine, producing muscle relaxation and pain relief, although in many cases its effect is not evident until several days have passed. Lidocaine is an amide type local anesthetic with an intermediate duration of action, which act by preventing the propagation of nerve impulses by decreasing the permeability of sodium channels. The objective of this study was to test whether adding LA to the BT dose, we got a shortening in the time of the reduction of EVA and improvement in quality of life. Material and methods: the study design was prospective, controlled, longitudinal and randomized in which we have evaluated the evolution of 20 patients randomly divided into two groups. The first group were given BT A type (group T). The second group was treated with BT A type and an additional dose of 2 % lidocaine (group TL). Previously, both groups had responded positively to a test with lidocaine 2 % infiltration of the affected muscle. Monitoring patients was sequentially to 3, 7, 15 and 90 days of treatment performed. For statistical analysis we used an analysis of variance, ANOVA, complemented by Mauchly test for sphericity check and by Greenhouse-Geisser test, with a confidence interval of 95 %, considering p < 0.05 to establish statistical differences. Results: there was statistically significant difference between group EVA TL and TB in the assessment on the third day, just as in the evaluation of Lattinen Index. No significant differences in the other reviews. In both groups there was significant difference in EVA reduction and Lattinen Index improvement at the beginning and end of the study. Conclusions: BT-A presents an alternative to the management of this condition when conservative therapy has failed. Local anesthetics cause a predictable, short and reversible muscle relaxation caused by blocking nerve conduction in nerve endings, while BT acts on the neuronal endings of the motor plate, preventing the release of acetylcholine. Its action is exercised in different places and with different characteristics. The action of local anesthetics is almost instantaneous and short, the TXB action is delayed and long lasting, so both can be complementary and agonists in their final effect

Increased myo-inositol in parietal white and gray matter as a biomarker of poor prognosis in neuropsychiatric lupus: a case report.

Neuropsychiatric manifestations can be a serious complication of systemic lupus erythematosus, affecting nearly 56% of these patients. Frequently, acceptable clinical outcome is observed in neurolupus with immunosuppressive therapy. Different metabolites identified with MR spectroscopy may be associated with modifications in the natural history of this disease, specifically in the central nervous system. We report a case of neurolupus with progressive neurologic impairment despite aggressive immunosuppressive treatment. We describe clinical features, laboratory and MRI results, as well as characteristic findings on MR spectroscopy. Serial MRI identified atrophy of the left temporal lobe. MR spectroscopy showed an increase of myo-inositol/creatine ratio intensity, accompanied by a decrease of N-acetylaspartate/creatine ratio in both parietal white and gray matter. During follow-up, the patient developed progressive cognitive deficiency despite the intensification of therapy. Neurolupus manifestations are common and immunosuppressive treatment often avoids severe complications. Characteristic findings on MR spectroscopy may be useful for clinicians to determine poor prognosis and resistance to therapy.

Marco legal del anestesiólogo en la cirugía mayor ambulatoria / Legal framework of the anesthesioiogist in a day case surgery

El marco legal del anestesiólogo en Cirugía Mayor Ambulatoria está cobrando relativa importancia en los últimos años. Cada vez más los profesionales vamos tomando conciencia de las implicaciones legales en las que podemos incurrir al realizar nuestro trabajo diario. El análisis de sentencias judiciales en España demuestra que es una especialidad con altas cuantías indemnizatorias. Es muy importante que los anestesiólogos conozcamos todo lo relativo a las normas de los servicios y centros donde desarrollamos nuestra labor asistencial, de igual manera debemos conocer las normas de los colegios profesionales y de las sociedades científicas, y las leyes de ámbito regional y estatal que afectan a nuestro trabajo (AU)

The legal framework anesthesiologist at Ambulatory Surgery, is gaining on importance in recent years, more and more professionals will become aware of the legal implications you may incur while performing our daily work. Analysis of court decisions in Spain shows that anesthesiology is a specialty with high compensatory amounts. It is very important that anesthesiologists know everything about standards of services and facilities where we do care work, just as we must know the rules of professional associations and scientific societies, and the laws of regional and state level that affect our work (AU)

Systemic sclerosis sine scleroderma and limited cutaneous systemic sclerosis: similarities and differences.

OBJECTIVES: To compare a cohort of patients with systemic sclerosis sine scleroderma (ssSSc) vs. patients with limited cutaneous systemic sclerosis (lcSSc). METHODS: Forty-five patients with ssSSc and 186 patients with lcSSc were investigated. Demographic, clinical and immunologic features and survival were compared. RESULTS: There were no significant differences between ssSSc and lcSSc in gender, age at onset and interval between onset and diagnosis. ssSSc patients fulfilled the ACR criteria for SSc less than lcSSc patients (13%/77%, p<0.0001). There were no significant differences in articular involvement, myopathy, tendon friction rubs and gastrointestinal, pulmonary, cardiac and renal involvements. There was a trend to higher prevalence of pulmonary arterial hypertension (PAH) in ssSSc patients (29%/19%) but not reach significant difference. The prevalence of antinuclear and anticentromere antibodies and slow capilaroscopic pattern was similar. Sicca syndrome (13%/30%; p=0.024), digital ulcers (16%/50%; p<0.0001), calcinosis (11%/26%; p=0.047) and acroosteolysis (0% /10%; p=0.028) were more frequently in lcSSc. Survival at 5, 10, and 15 yr was not different in ssSSc and lcSSc patients (100%/98%, 100%/98%, and 92%/89%, respectively). CONCLUSIONS: ssSSc and lcSSc patients share demographic, clinical and immunologic features. Survival is also similar in both groups. Differences are mainly due to peripheral vascular manifestations. However, despite great similarities, we believe that ssSSc patients should be considered as a different subset in order to avoid misdiagnosis. ssSSc patients should be truly differentiated from early SSc using sensitive and specific studies looking for any asymptomatic organ involvement.

The indocyanine green method is equivalent to the 99mTc-labeled radiotracer method for identifying the sentinel node in breast cancer: a concordance and validation study.

AIMS: The aim of this study was to assess concordance between the indocyanine green (ICG) method and (99m)Tc-radiotracer method to identify the sentinel node (SN) in breast cancer. Evidence supports the feasibility and efficacy of the ICG to identify the SN, however this method has not been prospectively compared with the gold-standard radiotracer method in terms of SN detection rate. METHODS: Between June 2011 and January 2013, 134 women with clinically node-negative early breast cancer received subdermal/peritumoral injection of (99m)Tc-labeled tracer for lymphoscintigraphy, followed by intraoperative injection of ICG for fluorescence detection of SNs using an exciting light source combined with a camera. In all patients, SNs were first identified by the fluorescence method (ICG-positive) and removed. A gamma ray-detecting probe was then used to determine whether ICG-positive SNs were hot ((99m)Tc-positive) and to identify and remove any (99m)Tc-positive (ICG-negative) SNs remaining in the axilla. The study was powered to perform an equivalence analysis. RESULTS: The 134 patients provided 246 SNs, detected by one or both methods. 1, 2 and 3 SNs, respectively, were detected, removed and examined in 70 (52.2%), 39 (29.1%) and 17 (12.7%) patients; 4-10 SNs were detected and examined in the remaining 8 patients. The two methods were concordant for 230/246 (93.5%) SNs and discordant for 16 (6.5%) SNs. The ICG method detected 99.6% of all SNs. CONCLUSIONS: Fluorescent lymphangiography with ICG allows easy identification of axillary SNs, at a frequency not inferior to that of radiotracer, and can be used alone to reliably identify SNs.

Tailoring treatment for ductal intraepithelial neoplasia of the breast according to Ki-67 and molecular phenotype.

BACKGROUND: The post-surgical management of ductal intraepithelial neoplasia (DIN) of the breast is still a dilemma. Ki-67 labelling index (LI) has been proposed as an independent predictive and prognostic factor in early breast cancer. METHODS: The prognostic and predictive roles of Ki-67 LI were evaluated with a multivariable Cox regression model in a cohort of 1171 consecutive patients operated for DIN in a single institution from 1997 to 2007. RESULTS: Radiotherapy (RT) was protective in subjects with DIN with Ki-67 LI ≥ 14%, whereas no evidence of benefit was seen for Ki-67 LI <14%, irrespective of nuclear grade and presence of necrosis. Notably, the higher the Ki-67 LI, the stronger the effect of RT (P-interaction <0.01). Hormonal therapy (HT) was effective in both Luminal A (adjusted hazard ratio (HR)=0.56 (95% CI, 0.33-0.97)) and Luminal B/Her2neg DIN (HR 0.51 (95% CI, 0.27-0.95)). CONCLUSION: Our data suggest that Ki-67 LI may be a useful prognostic and predictive adjunct in DIN patients. The Ki-67 LI of 14% could be a potential cutoff for better categorising this population of women at increased risk for breast cancer and in which adjuvant treatment (RT, HT) should be differently addressed, independent of histological grade and presence of necrosis.

[Comparison of glycemic control in diabetic patients with and without metabolic syndrome]. / Comparación del control glucémico en pacientes diabéticos con y sin síndrome metabólico.

OBJECTIVE: To compare the glycemic level patients with type 2 diabetes (T2DM) with and without Metabolic syndrome (MS). METHODOLOGY: cross sectional study. Included patients randomly DM2 corroborated in your clinical record. The SM was identified in patients with at least 3 of 5 criteria of ATP III (Adult Treatment Panel III). A questionnaire was structured. Hemoglobin was determined (HbA1c), HDL-cholesterol, triglycerides, hypertension (HBP), body mass index (BMI), waist circumference (WC) and hip (NCC). RESULTS: 283 patients were included. Mean age was 59.8 ± 10.6. The predominant sex was female (73.6%). SM Criteria were : low HDL: 62.9%; hypertriglyceridemia: 56.3%; obesity abdominal (OA) 90.1%, hypertension (HBP): 62.5%. The prevalence of MS was 86.6% (95% CI 83% to 89%). There was significant difference in mean HbA1c level in patients with and without MS, HAS, OR, and low HDL. In contrast, subjects with hypertriglyceridemia had an HbA1c level significantly higher than those without hypertriglyceridemia (8.9% 2.3 vs 8.5% 2.1, respectively, P = 0.01). HbA1c is positively correlated with triglycerides (r = 0.24, p = 0.001), and negatively with weight (r = -0.19, p = 0.001), BMI (r = -0172, p = 0.004), CCI (r = -0.12, P = 0.004) and CCA (r = -0.14, p = 0.02). In adjusted multivariate analysis, only the duration of diabetes was associated with glycemic level (OR = 1.014, 95% in 1.010 to 1.016). CONCLUSIONS: We not found differences significant glycemic level in patients with and without MS.

Objetivo: Comparar el nivel glucémico en pacientes con diabetes tipo 2 (DM2) con y sin síndrome metabólico (SM). Metodología: Estudio transversal analítico. Se incluyeron aleatoriamente pacientes con DM2 corroborado en su expediente clínico. El SM se identificó en pacientes con al menos 3 de 5 criterios del ATP III (AdultTreatment Panel III). Se aplicó un cuestionario estructurado. Se determinó hemoglobina glucosilada (HbA1c), colesterol-HDL, triglicéridos, hipertensión arterial sistémica (HAS), índice de masa corporal (IMC), circunferencia de cintura (CCi) y cadera (CCa). Plan de análisis: prevalencia, prueba t de Student, correlación de Pearson y regresión logística. Resultados: Se incluyeron 283 pacientes. Edad promedio: 59.8±10.6 años. Predominó el sexo femenino (73.6%)Criterios cubiertos para SM: hipocolesterolemia-HDL: 62.9%; hipertrigliceridemia: 56.3%; obesidad abdominal (OA) 90.1%; hipertensión arterial sistémica (HAS): 62.5%. La prevalencia de SM fue 86.6% (IC95% 83% a 89%). No hubo diferencia significativa en el promedio de HbA1c en pacientes con y sin SM, HAS, OA, e hipocolesterolemia-HDL. En cambio, sujetos con hipertrigliceridemia tuvieron un promedio significativamente mayor de HbA1c que aquellos sin hipertrigliceridemia (8.9±2.3 vs 8.5±2.1, respectivamente; p=0.01). HbA1c correlacionó positivamente con trigliceridemia (r=0.24, p=0.001), y negativamente con el peso (r= -0.19, p=0.001), IMC (r= -0.172, p=0.004), CCi (r= -0.12, p=0.004) y CCa (r=-0.14, p=0.02). En el análisis multivariado ajustado, solamente la duración de la diabetes se asoció con el nivel glucémico (OR= 1.014, IC95% 1.010 a 1.016). Conclusiones: No encontramos diferencias significativas en el nivel glucémico en pacientes con y sin SM.