Evaluation of Plasma Disappearance Rate Indocyanine Green Clearance as a Predictor of Liver Graft Rejection in Donor Brain Death.

INTRODUCTION: There currently exist no quantitative methods to assess graft viability before the donor procurement procedure. In Europe, around 20% of liver grafts evaluated "in situ" by an experienced surgeon are discarded. The aim of this study is to evaluate the use of the plasma disappearance rate indocyanine green (PDR-ICG) clearance in predicting liver graft rejection to avoid this 20% of futile surgeries. OBJECTIVES: To evaluate PDR-ICG as a predictor of liver graft rejection in death brain donors compared with the gold standard evaluation by an experienced surgeon. MATERIAL AND METHODS: Prospective observational single center study. From March 2017 to July 2019, 29 donors were included in the study, 17 were men and 12 women with a median age of 68 years ± 16.9 years. Donors had an intensive care unit stay of 2 days ± 4 days. PDR-ICG was measured with PICCO2 monitor. Indocyanine green clearance dose was 0.25 mg/kg injected intravenously in the operating room just before donor procurement procedure is initiated. The surgeon was unaware of the PDR-ICG measure until the decision of graft acceptance was taken. Data regarding the donors and biopsy results were included in a prospective database. RESULTS: PDR-ICG measure could be obtained in 10 minutes in all of the cases included. The median PDR-ICG obtained was 18%/min (range, 2.4-31%/min). Graft rejection took place in 15 out of the 29 donors. PDR-ICG value was less than 10%/min in 6 of these rejected grafts and less than 15%/min in 10 donors. All donor grafts with PDR-ICG <15% were discarded. The graft had been discarded in 5 donors with a PDR-ICG >15%. CONCLUSIONS: In our study a plasma disappearance rate <10 would have identified the grafts that would be rejected, thus avoiding the displacement work and expense of the surgical team. These results should be confirmed in a multicentric study.

Donor Risk Index Has an Impact in Intraoperative Measure of Hepatic Artery Flow and in Clearance of Indocyanine Green: An Observational Cohort Study.

BACKGROUND: The increase in indications for liver transplantation has led to acceptance of donors with expanded criteria. The donor risk index (DRI) was validated with the aim of being a predictive model of graft survival based on donor characteristics. Intraoperative arterial hepatic flow and indocyanine green clearance (plasma clearance rate of indocyanine green [ICG-PDR]) are easily measurable variables in the intraoperative period that may be influenced by graft quality. Our aim was to analyze the influence of DRI on intraoperative liver hemodynamic alterations and on intraoperative dynamic liver function testing (ICG-PDR). METHODS: This investigation was an observational study of a single-center cohort (n = 228) with prospective data collection and retrospective data analysis. Measurement of intraoperative flow was made with a VeriQ flowmeter based on measurement of transit time (MFTT). The ICG-PDR was obtained from all patients with a LiMON monitor (Pulsion Medical Systems AG, Munich, Germany). DRI was calculated using a previously validated formula. Normally distributed variables were compared using Student's t test. Otherwise, the Mann-Whitney U test or Kruskal-Wallis test was applied, depending on whether there were 2 or more comparable groups. The qualitative variables and risk measurements were analyzed using the chi-square test. P < .05 was considered statistically significant. RESULTS: DRI score (mean ± SD) was 1.58 ± 0.31. The group with DRI >1.7 (poor quality) had an intraoperative arterial flow of 234.2 ± 121.35 mL/min compared with the group having DRI < 1.7 (high quality), with an intraoperative arterial flow of 287.24 ± 156.84 mL/min (P = .02). The group with DRI >1.70 had an ICG-PDR of 14.75 ± 6.52%/min at 60 minutes after reperfusion compared to the group with DRI <1.70, with an ICG-PDR of 16.68 ± 6.47%/min at 60 minutes after reperfusion (P = .09). CONCLUSION: Poor quality grafts have greater susceptibility to ischemia-reperfusion damage. Decreased intraoperative hepatic arterial flow may represent an increase in intrahepatic resistance early in the intraoperative period.

Role of intraoperative radiotherapy in the treatment of sacral chordoma.

BACKGROUND CONTEXT: Sacral chordoma is a rare entity with high local recurrence rates when complete resection is not achieved. To date, there are no series available in literature combining surgery and intraoperative radiotherapy (IORT). PURPOSE: The objective of this study was to report the experience of our center in the management of sacral chordoma combining radical resection with both external radiotherapy and IORT. STUDY DESIGN: This is a retrospective case series. PATIENT SAMPLE: The patient sample included 15 patients with sacral chordoma resected in our center from 1998 to 2015. OUTCOME MEASURES: The outcome measures were overall survival (OS), disease-free survival (DFS), and rates of local and distant recurrences. METHODS: We retrospectively reviewed the records of all the patients with sacral chordoma resected in our center from 1998 to December 2015. Overall survival, DFS, and rates of local and distant recurrences were calculated. Results between patients treated with or without IORT were compared. RESULTS: A total of 15 patients were identified: 8 men and 7 women. The median age was 59 years (range 28-77). Intraoperative radiotherapy was applied in nine patients and six were treated with surgical resection without IORT. In 13 patients, we performed the treatment of the primary tumor, and in two patients, we performed the treatment of recurrence disease. A posterior approach was used in four patients. Wide surgical margins (zero residue) were achieved in six patients, marginal margins (microscopic residue) were achieved in seven patients, and there were no patients with intralesional (R2) margins. At a median follow-up of 38 months (range 11-209 months), the 5-year OS in the IORT group was 100% versus 53% in the group of non-IORT (p=.05). The median DFS in the IORT group was 85 months, and that in the non-IORT group was 41 months. In the group without IORT, two patients died and nobody died during the follow-up in the group treated with IORT. High-sacrectomy treated patients had a median survival of 41 months, and low-sacrectomy treated patients had a median survival of 90 months. Disease-free survival in patients without gluteal involvement was 100% at 5 years, and that in patients with gluteal involvement was 40%. All patients with a recurrence in our study had gluteal involvement. CONCLUSIONS: Multidisciplinary management of sacral chordoma seems to improve local control. The use of IORT, in our experience, is associated with an increase in OS and DFS. The level of resection and gluteal involvement seems to affect survival. The posterior approach is useful in selected cases. Multicenter studies should be performed to confirm the utility of IORT.

Acute bleeding from pseudoaneurysms following liver and pancreatobiliary surgery.

PURPOSE: We report 12 patients with visceral PA following pancreato-biliary and hepatic surgery. RESULTS: Seven patients (7/11, 63 %) had developed postoperative complications from their original procedure; that information was missing in one patient. Bleeding occurred in eight (three with hemoperitoneum two with haemobilia, and three with GI bleeding through a biliary-enteric anastomosis), three were asymptomatic, and the other one presented with abdominal pain. Eleven patients had an interventional radiology procedure performed (Five underwent angioembolization, a stent was placed in four, and two patients underwent both procedures). Complications related to the procedure developed in 6 (54.5 %) patients, and surgery was required in four of them. CONCLUSION: Postoperative pseudoaneurysms (PA) of visceral arteries are rare and usually secondary to vascular injury after pancreato-biliary and liver surgery. They usually present with bleeding and nowadays most are amenable to initial control by interventional radiology.

Study of association of CTLA4 gene variants to non-anterior uveitis.

This study was undertaken to investigate the possible genetic association of functional CTLA4 polymorphisms with susceptibility to non-anterior uveitis. Four hundred and seventeen patients with endogenous non-anterior uveitis and 1517 healthy controls of Spanish Caucasian origin were genotyped for the CTLA4 polymorphisms rs733618, rs5742909 and rs231775, using predesigned TaqMan(©) allele discrimination assays. PLINK software was used for the statistical analyses. No significant associations between the CTLA4 polymorphisms and susceptibility to global non-anterior uveitis were found. It was also the case when the potential association of these genetic variants with the anatomical localization of the disease, such as intermediate, posterior or panuveitis, was assessed. Our results do not support a relevant role of these CTLA4 polymorphisms in the non-anterior uveitis genetic predisposition.

Actualización en el tratamiento de la dermatomiositis; a propósito de un caso / Update in the treatment of dermatomyositis; a case study

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Uveítis anterior bilateral aguda e hipersensibilidad a anticonvulsivantes / Bilateral acute anterior uveitis and anticonvulsant hypersensitivity syndrome

Caso clínico: Se presenta el caso de una paciente que tras la toma de oxcarbacepina (trileptal) desarrolló lesiones cutáneas en miembros inferiores y una uveítis anterior bilateral.DiscusiónLa presencia de uveítis en el contexto de una reacción alérgica a un anticonvulsivante es un hecho poco frecuente que traduce una afectación de órganos internos, por lo que debe ser tenida en cuenta en la valoración completa de un paciente con posible reacción de hipersensibilidad a un determinado fármaco (AU)

Clinical Case: A case is presented of a patient who developed skin lesions on the legs and a bilateral anterior uveitis after taking Oxcarbazepine (Trileptal)DiscussionThe presence of uveitis in the context of an allergic reaction to an anticonvulsant is a very uncommon and can affect the internal organs. For this reason, it should be taken into account when carrying out a full assessment of a patient with a possible hypersensitivity reaction to a particular drug (AU)

[HIV retinal vasculitis]. / Vasculitis retiniana por VIH.

CASE REPORT: We present a case of a 47 year-old woman, infected with human immunodeficiency virus (HIV) diagnosed 5 years ago without receiving any treatment, who had floaters in her left eye. A peripheral retinal vasculitis was discovered and confirmed by an angiography. No source of infection was found, antiretroviral and corticosteroid treatment was given, with a complete resolution of the vasculitis. DISCUSSION: From 70-80% of positive untreated HIV patients develop ocular complications, with intraocular inflammation in more than half of them. Intraocular inflammation can be associated with opportunistic infections, tumours and as in our case, secondary to the HIV. Antiretroviral therapy is the proper treatment in these patients.

Vasculitis retiniana por VIH / HIV retinal vasculitis

Caso clínico: Mujer de 47 años con infección por el virus de la inmunodeficiencia humana(VIH) de 5 años de evolución sin tratamiento que acude por miodesopsias. Se le halla unfoco de vasculitis retiniana periférica en el ojo izquierdo (OI) confirmado angiográficamente.Se descarta otra patología infecciosa por parte de Medicina Interna y se inicia tratamientoantirretroviral y corticoideo sistémico, con resolución del foco de vasculitis.Discusión: Entre un 70 y un 80% de los pacientes positivos para VIH sin tratamiento desarrollancomplicaciones oculares, con inflamación intraocular en más de la mitad de ellos.La inflamación intraocular puede ser debida a infecciones oportunistas, neoplasias y, comoen nuestro caso, secundarias al propio virus. En estos pacientes el tratamiento antirretroviralconsigue la resolución del cuadro(AU)

Case report: We present a case of a 47 year-old woman, infected with humanimmunodeficiency virus (HIV) diagnosed 5 years ago without receiving any treatment, whohad floaters in her left eye. A peripheral retinal vasculitis was discovered and confirmed byan angiography. No source of infection was found, antiretroviral and corticosteroidtreatment was given, with a complete resolution of the vasculitis.Discussion: From 70-80% of positive untreated HIV patients develop ocular complications,with intraocular inflammation in more than half of them. Intraocular inflammation can beassociated with opportunistic infections, tumours and as in our case, secondary to the HIV.Antiretroviral therapy is the proper treatment in these patients(AU)

[Bilateral acute anterior uveitis and anticonvulsant hypersensitivity syndrome]. / Uveítis anterior bilateral aguda e hipersensibilidad a anticonvulsivantes.

CLINICAL CASE: A case is presented of a patient who developed skin lesions on the legs and a bilateral anterior uveitis after taking Oxcarbazepine (Trileptal). DISCUSSION: The presence of uveitis in the context of an allergic reaction to an anticonvulsant is a very uncommon and can affect the internal organs. For this reason, it should be taken into account when carrying out a full assessment of a patient with a possible hypersensitivity reaction to a particular drug.

[OCT in acute anterior uveitis]. / OCT en uveítis anteriores agudas.

PURPOSE: To evaluate macular thickening, the state of the optic disc and retinal nerve fibers layer (RFNL) in patients with an actual episode of acute anterior uvetis (AAU) by optical coherence tomography (OCT), and compare them with a control group. METHODS: In this prospective, cross-sectional, observational and controlled study we recruited 27 consecutive eyes of 20 patients with an actual episode of AAU, age and sex-matched with 40 healthy eyes of 20 volunteers. The age ranged between 8 and 78 years old, and all were evaluated by the <>, <> and <> scans by OCT. The patients were evaluated twice in a period of 1 month in order to obtain an average between the two measurements by OCT. RESULTS: We found a statistically significant increase in macular volume in AAU eyes compared with control eyes. Total macular volume in uveitic eyes was 7.3 SD 0.6 mm(3) and in healthy eyes was 7.01 SD 0.3 mm(3) (mean SD standard deviation) (p<0.001). Indeed, we found a statistically significant increase in the superior RFNL thickness compared with controls. The Smax/Imax measurement was 1.05 SD 0.1 in pathological eyes and in healthy eyes it was 0.97 SD 0.1 (p<0.02). CONCLUSION: We found by OCT that patients suffering an AAU showed an increase in macular volume and superior RFNL thickness versus control eyes in the acute episode.

OCT en uveítis anteriores agudas / OCT in acute anterior uveitis

Propósito: Evaluar el grosor macular, el estado delnervio óptico y de la capa de fibras nerviosas retinianas(CFNR) en pacientes con un episodio deuveítis anterior aguda (UAA) mediante OCT, ycomparar los resultados con un grupo control.Método: En este estudio prospectivo, transversal,observacional y controlado, reclutamos 27 ojos de20 pacientes con brote agudo de UAA, a los cualesse les empató por sexo y edad con 40 ojos de 20voluntarios sanos. El rango de edad de los pacientesfue 8-78 años, siendo evaluados mediante los scansde OCT ®fast macular thickness», ®fast optic disc»and ®fast RFNL thickness». Se hicieron dos medicionespor OCT a los pacientes, una al inicio y otraal mes del episodio, para obtener una medida promedio.Resultados: Encontramos un incremento en elvolumen macular estadísticamente significativo enlos ojos con UAA comparados con los ojos controles.El volumen macular total en los ojos con brotefue 7,3 DE 0,6 mm3 mientras que en los ojos controlesfue 7,01 DE 0,3 mm3 (p<0,001) (DE significadesviación estándar). Además, encontramos unaumento estadísticamente significativo en el grosorde las fibras del hemicampo superior de la CFNRcomparadas con las de los controles. El cociente Smax/Imax fue 1,05 DE 0,1 en los ojos patológicosy en los controles fue 0,97 DE 0,1 (p<0,02).Conclusiones: Encontramos que los pacientes quepresentaban un brote agudo de UAA tenían unincremento del volumen macular y del grosor de lacapa de fibras del hemicampo superior retinianocomparados con los ojos controles(AU)

Purpose: To evaluate macular thickening, the stateof the optic disc and retinal nerve fibers layer(RFNL) in patients with an actual episode of acuteanterior uvetis (AAU) by optical coherence tomography(OCT), and compare them with a controlgroup.Methods: In this prospective, cross-sectional, observationaland controlled study we recruited 27 consecutiveeyes of 20 patients with an actual episode ofAAU, age and sex-matched with 40 healthy eyes of20 volunteers. The age ranged between 8 and 78years old, and all were evaluated by the ®fast macularthickness», ®fast optic disc» and ®fast RFNLthickness» scans by OCT. The patients were evaluatedtwice in a period of 1 month in order to obtain anaverage between the two measurements by OCT.Results: We found a statistically significant increasein macular volume in AAU eyes compared withcontrol eyes. Total macular volume in uveitic eyeswas 7.3 SD 0.6 mm3 and in healthy eyes was 7.01SD 0.3 mm3 (mean SD standard deviation)(p<0.001). Indeed, we found a statistically significantincrease in the superior RFNL thickness comparedwith controls. The Smax/Imax measurementwas 1.05 SD 0.1 in pathological eyes and in healthyeyes it was 0.97 SD 0.1 (p<0.02). Conclusion: We found by OCT that patients sufferingan AAU showed an increase in macular volumeand superior RFNL thickness versus controleyes in the acute episode(AU)

[Spontaneous primary uveal effusion syndrome]. / Síndrome de efusión uveal espontáneo.

CLINICAL CASE: This was a 73 year-old male patient who developed an apparent uveal effusion syndrome in his right eye one year after cataract surgery. Once possible associated conditions were discarded, a diagnosis of spontaneous uveal effusion syndrome was reached. With appropriate systemic steroid therapy, a favourable response occurred. DISCUSSION: The diagnosis of uveal effusion may sometimes be difficult to establish. In order to diagnose and manage these patients, a detailed clinical examination along with fluorescein angiography, ultrasonography, ultrasound biomicroscopy (UBM) and magnetic resonance imaging (MRI) tests, must be carried out.

[Neuroschistosomiasis: a challenging diagnosis]. / Neuroesquistosomiasis: un reto para el diagnóstico.

INTRODUCTION: Neuroschistosomiasis is an uncommon and under diagnosed disease in our country because of the no clinical suspicion. The most common neurological manifestations are epileptic seizures as central nervous system involvement or different types of myelopathies: transverse myelitis, myeloradiculopathy, cauda equina syndrome or Brown-Sequard syndrome. CASE REPORT: A 27 years-old male from an endemic area, with atypical neurological affectation as he presented myelopathy and multifocal neuritis. Diagnosis was based on the epidemiological exposure datums, the myelopathy, the positive serological studies for Schistosoma haematobium, no detection of other parasitic infections and the clinical and radiological improvement after treatment. Cervical and thoracic magnetic resonance showed areas of hyper signal in T2 as it was described in other cases. It was detected S. haematobium in the bladder, the rest of serological and microbiological studies were negative. Besides, eosinophils on the biopsy of sural nerve orientative to parasitic etiology. CONCLUSION: In patient with myelopathy or another unexplained neurological manifestation we have to suspect neuroschistosomiasis. In a world where migrations and travels are so frequent we have to think in this type of diseases.

Neuroesquistosomiasis: un reto para el diagnóstico / Neurochistosomiasis: a challenging diagnosis

Introducción. La neuroesquistosomiasis es una entidad poco frecuente e infradiagnosticada en nuestro medio por la falta de sospecha clínica. Las formas más habituales de presentación son afectación cerebral o distintas variantes de mielopatías: mielitis transversa, mielorradiculopatía, síndrome de cola de caballo, síndrome de Brown-Séquard. Caso clínico. Varón de 27 años oriundo de zona endémica, con afectación neurológica atípica, pues presenta sintomatología medular y neuropatía multifocal. Los datos epidemiológicos de exposición, la clínica de mielopatía, la serología positiva para Schistosoma haematobium, el descarte de otras posibles parasitosis y la mejoría tanto clínica como radiológica tras el tratamiento nos han permitido llegar al diagnóstico. Las imágenes cervicales y dorsales observadas en la resonancia magnética son similares a las descritas en otras ocasiones. En la investigación etiológica se detecta S. haematobium vesical, siendo el resto de serologías y análisis microbiológicos negativos. Además la presencia de eosinófilos en la biopsia del nervio sural orienta hacia el origen parasitario de dicha afectación. Conclusión. Ante un paciente con mielopatía u otra afectación neurológica no explicada debemos sospechar neuroesquistomiasis. En un mundo donde las migraciones y los viajes son tan frecuentes, cada día debemos pensar más en este tipo de enfermedades de origen tropical

Introduction. Neuroschistosomiasis is an uncommon and under diagnosed disease in our country because of the no clinical suspicion. The most common neurological manifestations are epileptic seizures as central nervous system involvement or different types of myelopathies: transverse myelitis, myeloradiculopathy, cauda equina syndrome or Brown-Séquard syndrome. Case report. A 27 years-old male from an endemic area, with atypical neurological affectation as he presented myelopathy and multifocal neuritis. Diagnosis was based on the epidemiological exposure datums, the myelopathy, the positive serological studies for Schistosoma haematobium, no detection of other parasitic infections and the clinical and radiological improvement after treatment. Cervical and thoracic magnetic resonance showed areas of hyper signal in T2 as it was described in other cases. It was detected S. haematobium in the bladder, the rest of serological and microbiological studies were negative. Besides, eosinophils on the biopsy of sural nerve orientative to parasitic etiology. Conclusion. In patient with myelopathy or another unexplained neurological manifestation we have to suspect neuroschistosomiasis. In a world where migrations and travels are so frequents we have to think in this type of diseases

[Retinal neovascularization in a traumatic microhyphema]. / Neovascularización retiniana en microhifema traumático.

CLINICAL CASE: This is a case of retinal ischaemia with subsequent neovascularization, in a 13 year-old boy who sustained a traumatic hyphema after blunt trauma. DISCUSSION: Hyphemas can occur after blunt trauma, intraocular surgery, spontaneously and in association with the use of substances that alter platelet or thrombin function (aspirin, ethanol). Associated injuries are traumatic anterior uveitis, iridodialysis, optic atrophy, secondary hemorrhage and a traumatic cataract. This case illustrates the formation of retinal neovascularization in association with a microhyphema and the need for careful and prolonged ophthalmological examination in this clinical context.

Neovascularización retiniana en microhifema traumático / Retinal neovascularization in a traumatic microhyphema

Caso clínico: Informar un caso de isquemia retiniana con desarrollo de neovascularización, en un niño de 13 años con hifema traumático después de traumatismo contuso. Discusión: El hifema puede ocurrir después de un trauma contuso, cirugía intraocular, espontáneamente y en asociación con el empleo de sustancias que alteran la función de plaquetas o trombina (aspirina, etanol). Daños asociados incluyen uveítis anterior traumática, iridodiálisis, atrofia óptica, hemorragia y catarata. Este caso demuestra la posible formación de neovascularización retiniana asociado a microhifema y la necesidad de un examen oftalmológico prolongado en este contexto

Clinical case: This is a case of retinal ischaemia with subsequent neovascularization, in a 13 yearold boy who sustained a traumatic hyphema after blunt trauma. Discussion: Hyphemas can occur after blunt trauma, intraocular surgery, spontaneously and in association with the use of substances that alter platelet or thrombin function (aspirin, ethanol). Associated injuries are traumatic anterior uveitis, iridodialysis, optic atrophy, secondary hemorrhage and a traumatic cataract. This case illustrates the formation of retinal neovascularization in association with a microhyphema and the need for careful and prolonged ophthalmological examination in this clinical context

Anterior uveitis and meningococcemia: a case report.

PURPOSE: To describe a case of meningococcemia with anterior uveitis. METHODS: Observational case report. RESULTS: A 38-year-old woman developed meningococcal septicemia caused by Neisseria meningitidis type B. During her admission, she had pain in her left eye, inflammatory cells, and a fibrinous exudate in the anterior chamber and multiple posterior synechiae, all in the context of an anterior uveitis. She was treated with topical steroids and mydriatics with resolution of ocular inflammation. CONCLUSIONS: This case illustrates the possible association between anterior uveitis and a meningococcal septicemia, and the need for careful ophthalmologic examination when a red eye develops in this clinical context.