A randomised controlled feasibility trial of a clinical protocol to manage hypotension during major non-cardiac surgery.

Intra-operative hypotension is a risk factor for postoperative morbidity and mortality. Minimally invasive monitors that derive other haemodynamic parameters, such as stroke volume, may better inform the management of hypotension. As a prelude to a multicentre randomised controlled trial, we conducted a single-centre feasibility trial of a protocol to treat hypotension as informed by minimally invasive haemodynamic monitoring during non-cardiac surgery. We recruited adults aged ≥40 years with cardiovascular risk factors who underwent non-cardiac surgery requiring invasive arterial pressure monitoring. Participants were randomly allocated to usual care, or a clinical protocol informed by an arterial waveform contour analysis monitor. Participants, outcome assessors, clinicians outside operating theatres and analysts were blinded to treatment allocation. Feasibility was evaluated based on: consent rate; recruitment rate; structured feedback from anaesthesia providers; and between-group differences in blood pressure, processes-of-care and outcomes. The consent rate among eligible patients was 33%, with 30 participants randomly allocated to the protocol and 30 to usual care. Anaesthesia providers rated the protocol to be feasible and acceptable. The protocol was associated with reduced fluid balance and hypotension exposure in the peri-operative setting. Postoperative complications included: acute myocardial injury in 18 (30%); acute kidney injury in 17 (28%); and surgical site infection in 7 (12%). The severity of complications was rated as moderate or severe in 25 (42%) participants. In summary, this single-centre study confirmed the feasibility of a multicentre trial to assess the efficacy and safety of a physiologically guided treatment protocol for intra-operative hypotension based on minimally invasive haemodynamic monitors.

Benefica chirurgia. A global surgery project focusing on hernia surgery.

BACKGROUND: The aim of international health cooperation projects is to alleviate the deficiencies in the area of health in low resource settings. Hernia surgery is a procedure that is well suited to these missions, due to its low morbidity, the fact that it can be performed on an outpatient basis, and the improvement in quality of life that it provides. OBJECTIVE: To describe the results of Benefica Chirurgia (BC), a Spanish non-profit humanitarian association in hernia pathology. METHODS: Five one-week surgical campaigns were carried out in Ecuador between 2015 and 2019, involving anesthetists, general and pediatric surgeons. Surgical and medical equipment was provided and transported by BC. ASA I/II patients underwent surgery. RESULTS: Surgery was performed on 240 patients with hernia pathology on 27 days. Sixty-three per cent of patients were male and the mean age was 48.2 years (range: 1-83). Hernia location was inguinal in 113 patients, umbilical in 101, and other in 26. The anesthetic technique used was spinal in 185 patients (77.1%), local plus intravenous sedation in 31 (12.9%), and general in 24 (10%). The surgical technique used was hernioplasty in 191 patients, herniorrhaphy in 31, incisional hernia repair in 15 and herniotomy in three. Surgery was performed on an outpatient basis in 98.4% of cases. Morbidity was 2%. Long-term postoperative evaluation is very complex. CONCLUSION: These campaigns make a significant contribution to health in low resource settings and provide great personal satisfaction for those involved. Standards achieved in the immediate postoperative period were similar to those obtained at the surgeons' centers in Europe. However, it is difficult to establish the rates of recurrence and chronic pain.

Association Between Three-Dimensional Left Ventricular Outflow Tract Area and Gradients After Myectomy in Hypertrophic Obstructive Cardiomyopathy.

OBJECTIVE: Determine whether the intraoperative three-dimensional left ventricular outflow tract cross-sectional area may be inversely correlated with pressure gradients as a determinant of surgical success after septal myectomy in hypertrophic cardiomyopathy patients. DESIGN: Perioperative data were obtained by retrospective review. SETTING: Toronto General Hospital, University of Toronto, Toronto, Canada, a tertiary hospital. PARTICIPANTS: The study comprised 67 patients with hypertrophic obstructive cardiomyopathy. INTERVENTIONS: Transthoracic and intraoperative transesophageal echocardiographic assessment of pressure gradients. Transesophageal measurement of the three-dimensional left ventricular outflow tract cross-sectional area. MEASUREMENTS AND MAIN RESULTS: The smallest left ventricular outflow tract area increased on average 1.883 cm2 (98.3%) after septal myectomy. There was a significant correlation between the increase in the area and the transesophageal pressure gradients (r = -0.32; p = 0.01) after myectomy, but none with postoperative transthoracic gradients at rest (r = -0.10; p = 0.42). Postoperative transesophageal and transthoracic gradients were significantly correlated (r = 0.26; p = 0.04). The best risk factors to predict high residual gradients were preoperative transesophageal gradient >97 mmHg, postoperative transesophageal area <3.16 cm2, and moderate or more residual transesophageal mitral regurgitation (specificity 89%, 81%, and 78%, respectively). CONCLUSIONS: Three-dimensional left ventricular outflow tract area measurements with transesophageal echocardiography after myectomy correlated fairly well with postoperative transesophageal pressure gradients. Patients with residual transthoracic elevated gradients after surgery at follow-up had a smaller transesophageal area and higher transesophageal pressure gradients immediately after the procedure. However, transesophageal pressure gradients after myectomy correlated poorly with follow-up transthoracic gradients at rest.

Ventriculitis por Listeria monocytogenes / Ventriculitis secondary to Listeria monocytogenes

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[Endoscopy-assisted surgery of the sellar region]. / Cirugía de la región selar asistida por endoscopia.

OBJECTIVE: To evaluate the usefulness of endoscopic assisted surgery of pituitary adenomas in transesphenoidal surgery, and in surgery of craneopharyngiomas using either minimally invasive approaches to the cranial base or transventricular approaches. MATERIAL AND METHODS: We present our preliminary experience in eleven patients operated of sellar region tumor by endoscopic assisted resection: 6 pituitary adenoma via transesphenoidal approach, 4 craneopharyngiomas 3 through supraciliar approach and 1 by transcortical transventricular approach, and 1 suprasellar cyst. RESULTS: By using the 30 degrees optic the use of endoscope allowed complete resection, confirmed by postoperative MRI, of all six pituitary macroadenomas providing control of resection of supraselar remnants. Complete resection was achieved in three out of four craneopharyngiomas, 2 of them being recurrences. Three were operated by using a supraciliar approach to the cranial base and in one case transcortical transventricular resection of a recurrent intraventricular craneopharyngioma was performed. In the case with partial resection remnant were let in place due to the close adherence to peritumoral structures. In the three craneopharyngiomas operated via supraciliar approach endoscope allowed better control of inferior aspect of ipsilateral optic nerve and internal carotid artery. In the case of intraventricular craneopharyngioma, the use of 30 degrees endoscope provide control of resection of the anterior part of third ventricle through the foramen of Monro with no additional opening. The suprasellar cyst was fenestrated. CONCLUSIONS: No matter which approach is going to be used in the resection of sellar tumors, endoscopy can play a crucial role in achieve complete resection with minimal morbidity by using minimally invasive procedures.

Cirugía de la región selar asistida por endoscopia / Endoscopy-assisted surgery of the sellar region

Objetivos: El estudio pretende evaluar la utilidad del uso del endoscopio en la cirugía de la región selar a través del abordaje transesfenoidal transnasal en los adenomas hipofisarios y a través de abordajes mínimamente invasivos a la base de cráneo o el sistema ventricular en el caso de craneofaringiomas. Material y métodos: Presentamos la experiencia preliminar en once casos intervenidos mediante cirugía asistida con endoscopia. Seis pacientes presentaban macroadenomas hipofisarios y fueron intervenidos por vía transesfenoidal transnasal. Cuatro pacientes presentaban craneofaringiomas, 2 de ellos recidivantes, que fueron abordados, 3 a través de un acceso supraciliar y uno mediante un abordaje transcortical transventricular, abordaje utilizado en un quiste supraselar intraventricular. Resultados : Se consiguió la exéresis completa confirmada por RM de los adenomas hipofisarios en los que el uso del endoscopio con óptica de 30° fue de utilidad en el control de la exéresis de los tumores con expansión supraselar. En el caso de los craneofaringiomas se alcanzó la exéresis completa en 3 de ellos uno de los cuales era recidivante, 2 por vía supraciliar y otro transcortical transventricular. En el caso restante, un craneofaringioma recidivante, la exéresis fue parcial por la íntima adherencia de la cápsula tumoral a las estructuras circundantes. En los 3 casos de acceso supraciliar, el endoscopio fue útil para el control de la exéresis del tumor localizado inferior al nervio óptico y la carótida interna ipsilaterales. En el acceso intraventricular el craneofaringioma que ocupaba el tercio anterior y medio del tercer ventrículo pudo resecarse a través del foramen de Monro, mediante una óptica de 30° que permitió controlar y resecar el resto tumoral del tercio anterior. El quiste fue fenestrado. Conclusiones: En cualquiera de las posibles vías de abordaje a la región selar, el uso de la cirugía asistida por endoscopia favorece una mayor radicalidad en la resección mediante el uso de abordajes mínimamente invasivos (AU)

Objective: To evaluate the usefulness of endoscopic assisted surgery of pituitary adenomas in transesphenoidal surgery, and in surgery of craneopharyngiomas using either minimally invasive approaches to the cranial base or transventricular approaches. Material and methods:We present our preliminary experience in eleven patients operated of sellar region umor by endoscopic assisted resection: 6 pituitary adenoma via transesphenoidal approach, 4 craneopharyngiomas 3 throung supraciliar approach and 1 by transcortical transventricular approach, and 1 suprasellar cyst. Results: By using the 30 degrees optic the use of endoscope allowed complete resection, confirmed by postoperative MRI, of all six pituitary macroadenomas providing control of resection of supraselar remnants. Complete resection was achieved in three out of four craneopharyngiomas, 2 of them being recurrences. Three were operated by using a supraciliar approach to the cranial base and in one case transcortical transventricular resection of a recurrent intraventricular craneopharyngioma was performed. In the case with partial resection remnant were let in place due to the close adherence to peritumoral structures. In the three craneopharyngiomas operated via supraciliar approach endoscope allowed better control of inferior aspect of ipsilateral optic nerve and internal carotid artery. In the case of intraventricular craneopharyngioma, the use of 30 degrees endoscope provide control of resection of the anterior part of third ventricle through the foramen of Monro with no additional opening. The suprasellar cyst was fenestrated. Conclusions: No matter which approach is going to be used in the resection of sellar tumors, endoscopy can play a crucial role in achieve complete resection with minimal morbidity by using minimally invasive procedures (AU)

Treatment of chronic he1patitis C genotype 1 with peginterferon-alpha2a (40 kDa) plus ribavirin under routine clinical practice in Spain: early prediction of sustained virological response rate.

BACKGROUND: Sustained virological response rates of up to 52% have been obtained with peginterferon alpha2a (40 kDa) plus ribavirin in patients suffering from chronic hepatitis C genotype 1 in randomized-controlled trials. AIM: To assess early virological response and its clinical utility in predicting an sustained virological response in patients suffering from chronic hepatitis C genotype 1 in routine clinical practice in Spain. METHODS: Treatment-naïve patients received pegylated interferon alpha2a (40 kDa) 180 microg/week plus ribavirin 1000/1200 mg/day for 48 weeks, and were followed for a further 24 weeks. Overall, 475 patients received at least one dose of medication and were included in the efficacy population. RESULTS: The overall sustained virological response rate was 48%. Of those with week 12 virological data, 83% had an early virological response. The negative predictive value of an early virological response was 93%. CONCLUSION: If sustained virological response is the goal, a treatment-decision based on a 12-week evaluation during routine clinical practice is feasible.

[Intrathecal baclofen and Botulinum toxin in infantile cerebral palsy]. / Baclofén intratecal y toxina botulínica en la parálisis cerebral infantil.

INTRODUCTION: Infantile cerebral palsy is considered to be a motor disorder affecting both posture and movement. It is the manifestation of a cerebral lesion that took place during the maturing process of the brain. Spastic cerebral palsy is the most frequent variety. The spasticity presented by these patients strongly influences their functioning and gives rise to several complications that affect their quality of life. AIMS AND DEVELOPMENT: The main aim of this study is to determine a set of suitable and effective therapeutic steps that can be used to improve patients' spasticity and to prevent the complications that stem from them, such as contractures, deformities, surgery, etc. Multiple treatments were used, including physiotherapy, rehabilitation and oral pharmacotherapy, with few satisfactory results. At present there are two very promising therapeutic alternatives for patients with infantile cerebral palsy: Botulinum toxin, which we already have a great deal of experience with, and intrathecal treatment with baclofen. We report on a series of 10 patients aged between 8 and 15 years who had had an intrathecal baclofen infusion pump implanted. To date (maximum follow-up: 12 months), their clinical course has been satisfactory in most cases, with no severe complications related to the surgical technique, except in one individual who presented a fistula that resolved spontaneously. CONCLUSIONS: Intrathecal baclofen seems to be a very useful alternative in the treatment of spasticity to improve the quality of life of these patients and those around them.

[Association between cerebral infarction and malignant glioma]. / Asociación de infarto cerebral y glioma maligno.

INTRODUCTION: It is very rare for cerebral infarction to be the first symptom of an intracranial tumour. Only three cases have been reported in which cerebral infarction is thought to have been caused by the arterial compromise triggered by incipient high grade gliomas that are not yet visible in radiological tests. CASE REPORT: A 46-year-old male with no relevant medical history or cardiovascular risk factors who presented with acute hemiplegia on the right-hand side of the body and a significantly impaired level of consciousness. Computerised axial tomography of the brain showed a left frontal malignant ischemic infarct that exerted an important mass effect. The patient was submitted to a left-side frontoparietal decompressive craniectomy. Post-operative progress was good and the patient even recovered his normal level of consciousness, although he was left with right hemiparesis and conduction dysphasia. Seven months after the craniectomy the patient experienced a progressive deterioration with symptoms of endocranial hypertension. Magnetic resonance imaging of the brain revealed the presence of a highly malignant tumour in the previously infarcted territory. A histological study of the excised lesion showed it to be a glioblastoma multiforme. CONCLUSIONS: The proximity in time, as well as the identical location of the two lesions, led us to think that the glioblastoma, although not yet visible in radiological explorations, affected a branch of the middle cerebral artery and gave rise to the infarct. Therefore, in the presence of a cerebral infarct in patients with no risk factors for suffering a brain vascular pathology, it is advisable to carry out a radiological follow-up so as to be able to diagnose a possible lesion due to a tumour.

Asociación de infarto cerebral y glioma maligno / Association between cerebral infarction and malignant glioma

Introducción. La primera manifestación de un tumor intracraneal raramente es la aparición de un infarto cerebral. Tan sólo se han documentado tres casos en los que se considera como causa de un infarto cerebral la afectación arterial provocada por gliomas incipientes de alto grado aún no visibles radiológicamente. Caso clínico. Se trata de un varón de 46 años sin antecedentes médicos de interés ni factores de riesgo cardiovasculares que presentó de manera aguda una manifiesta hemiplejía derecha y deterioro importante del nivel de conciencia. En la tomografía axial computarizada craneal se demostró un infarto isquémico maligno frontal izquierdo que ejercía un gran efecto de masa. Se practicó una craniectomía descompresiva frontoparietal izquierda. El posoperatorio fue favorable y el paciente recuperó hasta la normalidad su nivel de conciencia, aunque quedó con una hemiparesia derecha y disfasia de conducción. Siete meses después de la craniectomía, experimentó un deterioro progresivo con clínica de hipertensión endocraneal. La resonancia magnética cerebral demostró la presencia de un tumor de alto grado de malignidad sobre el territorio previamente infartado. El estudio histológico de la lesión resecada determinó que se trataba de un glioblastoma multiforme. Conclusión. La cercanía en el tiempo, así como la idéntica localización de ambas lesiones, hace pensar que el glioblastoma, no siendo aún visible radiológicamente, comprimió o invadió una rama de la arteria cerebral media y originó el infarto. Por tanto, ante la presencia de un infarto cerebral en un paciente sin factores de riesgo para sufrir patología vascular cerebral, sería recomendable realizar un seguimiento radiológico posterior con el fin de diagnosticar una posible lesión tumoral

Introduction. It is very rare for cerebral infarction to be the first symptom of an intracranial tumour. Only three cases have been reported in which cerebral infarction is thought to have been caused by the arterial compromise triggered by incipient high grade gliomas that are not yet visible in radiological tests. Case report. A 46-year-old male with no relevant medical history or cardiovascular risk factors who presented with acute hemiplegia on the right-hand side of the body and a significantly impaired level of consciousness. Computerised axial tomography of the brain showed a left frontal malignant ischemic infarct that exerted an important mass effect. The patient was submitted to a left-side frontoparietal decompressive craniectomy. Post-operative progress was good and the patient even recovered his normal level of consciousness, although he was left with right hemiparesis and conduction dysphasia. Seven months after the craniectomy the patient experienced a progressive deterioration with symptoms of endocranial hypertension. Magnetic resonance imaging of the brain revealed the presence of a highly malignant tumour in the previously infarcted territory. A histological study of the excised lesion showed it to be a glioblastoma multiforme. Conclusions. The proximity in time, as well as the identical location of the two lesions, led us to think that the glioblastoma, although not yet visible in radiological explorations, affected a branch of the middle cerebral artery and gave rise to the infarct. Therefore, in the presence of a cerebral infarct in patients with no risk factors for suffering a brain vascular pathology, it is advisable to carry out a radiological follow-up so as to be able to diagnose a possible lesion due to a tumour

Leucemia neutrofílica crónica: el interés del diagnóstico diferencial / Chronic neutrophilic leukemia: the worth of a complete differential diagnosis

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Sagittal synostosis: results of surgical treatment in 210 patients.

From 1977 to 1996, 210 patients suffering from scaphocephaly, have been operated on in our institutions. The surgical technique depended on the patients age. Single wide sagittal synostectomy was performed in 155 babies aged less than 3 months, obtaining good cosmetic results. Patients older than 3 months needed more complex and aggressive procedures to achieve similar results. The conclusions is that sagittal suturectomy is the proper treatment in younger patients under 3 months of age, and that a greater effort must be made to diagnose and treat these patients early.

[Spontaneous resolution of a congenital depressed skull fracture]. / Fractura hundimiento craneal congénita con resolución espontánea.

Congenital depressed skull fracture is rare and in most cases its etiology remains unclear. We present a female newborn infant with a congenital depressed skull fracture and no evidence of antepartum or intrapartum traumatism. The baby had normal neurological status and the depressed fracture healed spontaneously in a few weeks. Based on our experience of this case and a literature review, we conclude that congenital depressed skull fractures should be managed conservatively if the skull depression is less than 2cm, there is no previous trauma, no local edema or hematoma, and if the neonate shows normal neurological status.

Fractura-hundimiento craneal congénita con resolución espontánea / Spontaneous resolution of a congenital depressed skull fracture

Las fracturas craneales congénitas son un proceso poco frecuente cuya etiología queda en la mayoría de casos sin aclarar. Se presenta el caso de una recién nacida con fractura hundimiento craneal congénita, sin antecedente de traumatismo anteparto o intraparto, que evolucionó sin presentar ninguna sintomatología que, manteniendo una actitud expectante, presentó resolución espontánea de la fractura dentro de las primeras semanas de vida. Basándose en la experiencia de este caso y tras revisar la bibliografía sobre el tema la conclusión es que si no existe traumatismo previo, el recién nacido permanece neurológicamente asintomático, no hay signos locales de edema o hematoma y el hundimiento es menor de 2 cm, lo más recomendable consiste en una actitud expectante sin proceder a la reducción quirúrgica inmediata, ya que en estos casos la resolución espontánea es el resultado más probable (AU)

Method to determine the authenticity of aroma of saffron (Crocus sativus L.).

A thermal desorption-gas chromatography-mass spectrometry technique was applied to 252 different Spanish saffron samples (from La Mancha and Teruel). The average safranal content made up of 60% of the volatile fraction of the saffron. All the chromatograms obtained showed an interval between 8 and 18 min (retention time of safranal +/- 5 min) in which the silhouette of the chromatographic peaks was similar in all the samples. Therefore this interval can be used as a "fingerprint." Two examples are given which demonstrate the ability to use this "fingerprint" to detect adulteration.

[Prognostic factors in low-grade lymphoma]. / Investigación de factores pronósticos en linfomas de bajo grado.

PURPOSE: Prognostic factors in low grade non-Hodgkin's lymphoma (LGL) are not well established. The aim of this study is to investigate prognostic factors on LGL treated in our institution during the last decade. PATIENTS AND METHODS: The study was carried out on 70 cases of newly diagnosed LGL, most treated with CVP or clorambucil and prednisone. The median follow-up was 37 months (1-132). Variables reported as prognostic factors in previous series were subjected to bivariate and multivariate analysis. RESULTS: Relevant clinical features were: Ann Arbor III-IV stage 74%, ECOG > or = 2-17%, bone marrow involvement 60% and large tumor burden according to MD Anderson criteria 21%. Complete response (CR) was achieved in 50% and partial response in 29%. In bivariate analysis factors related with poor CR were B symptoms, large tumor burden, high LDH and more than one extranodal site involvement. Logistic regression showed that large tumor burden (p = 0.02; OR = 0.07) and B symptoms (p = 0.07; OR = 0.14) were the best prognostic factors of poor CR. Five year global survival (GS) was 55%, with a median of 76 months. In univariate analysis factors related with GS were ECOG > or = 2, B symptoms, bulky, large tumor burden, retroperitoneo involvement and absence of CR. In multivariate analysis the only factor related with poor GS was large tumor burden (p < 0.00001; RR = 5.93). When therapeutic response was included in the model, absence of CR (p = 0.008; RR = 3.40) and large tumour burden (p = 0.005; RR = 3.86) were the factors selected. CONCLUSIONS: In LGL tumor burden was the most important prognostic variable. Tumor response showed less importance than in high grade lymphomas.

Pediatric brain tumors: loss of heterozygosity at 17p and TP53 gene mutations.

Cytogenetic and molecular analyses of primitive neuroectodermal tumors (PNETs) of the central nervous system (CNS) have demonstrated material losses of 17p, the region that contains the TP53 gene, as the most frequent abnormality. Mutations in the TP53 gene are, however, very rare in these tumors. These findings strongly suggest that another, as yet unidentified, gene on 17p may be involved. We performed a search for loss of heterozygosity (LOH) on 17p by microsatellite markers on 26 childhood CNS tumors as well as TP53 gene mutations (exons 5-8) by single-strand conformational polymorphism analysis on 41 pediatric brain tumor samples of distinct histologic types. LOH was detected in 10 cases: 7 PNET, 2 astrocytomas, and 1 glioblastoma multiforme. In 4 of the PNETs the losses were limited to more distal markers. On the other hand, TP53 mutations were detected in 6 of 41 samples studied. Our results not only confirm the low penetrance of the TP53 gene on pediatric CNS tumors, but also provide further evidence of a putative tumor suppressor gene distal to TP53, between markers (D17S938, D17S926) and 17pter, specifically taking part in the development of PNET.