Use of MeNTS, Frailty and Symptom Scales for selecting surgical patients during the SARS-CoV-2 pandemic: A retrospective study / Uso de escalas MeNTS, Fragilidad y Síntomas para la selección de pacientes quirúrgicos durante la pandemia por SARS-CoV-2: Estudio retrospectivo

Abstract Introduction: The SARS-CoV-2 pandemic has led to the cancellation of non-emergent surgeries in order to optimize the use of resources. Once the elective medical services are restored, a technical and ethical strategy becomes critical to select candidate patients for elective surgery. Objective: To describe the results from the implementation of MeNTS (Medically Necessary Time-sensitive Procedures), FI-CGA, and survey on COVID-19 symptoms Scales, as methods for the selection of patients who were candidates for elective surgery during the SARS-CoV-2 pandemic, in a third level institution in Cali, Colombia. Methods: The databases of the results on the administration of MeNTS, frailty index (FI-CGA) and COVID 19 symptoms scales in patients who were candidates for elective surgery in a third level clinic in Cali city, between March 1st and August 31st, 2020 were reviewed. Results: A total of 1,044 patients were included, of which 647 (62.0 %) were females, with a median age of52 years (interquartile range [IQR] 38-62). 98 % of the patients were asymptomatic, the overall median score for MeNTS was 48 (IQR 44-52) and the average for FI-CGA was 0.0 (standard deviation 0.1). Conclusions: MeNTS, FI-CGA and the Symptoms Survey are easily accessible scales amidst the pandemic and are helpful to select patients with intermediate and low risk of perioperative morbidity in elective surgery during the SARS-CoV-2 pandemic. Further studies are required to confirm these findings and to clarify the potential of these tools in the selection of patients that meet the high-risk criteria.

Resumen Introducción: La pandemia por SARS-CoV-2 ha ocasionado la suspensión de cirugías no urgentes con el fin de optimizar los recursos. Una vez los servicios médicos electivos son restablecidos, es fundamental disponer de una estrategia técnica y ética para la selección de los pacientes candidatos a cirugía electiva. Objetivo: Describir los resultados observados durante la implementación de las escalas MeNTS (Medically Necessary Time-sensitive Procedures), IF-VIG y Encuesta de síntomas para COVID-19, como métodos de selección de pacientes candidatos a cirugía electiva durante la pandemia por SARS-CoV-2 en una institución de nivel tres en la ciudad de Cali, Colombia. Metodología: Se revisaron las bases de datos de los resultados de la aplicación de escalas de MeNTS, índice de fragilidad (IF-VIG) y los síntomas para COVID 19, en pacientes candidatos a cirugía electiva en una clínica de tercer nivel en la ciudad de Cali, entre marzo 1 y agosto 31 del 2020. Resultados: En total 1.044 pacientes fueron incluidos, de los cuales 647 (62,0 %) fueron mujeres con una mediana de edad de 52 años (rango intercuartil [RIC] 38-62). El 98 % de los pacientes estuvieron asintomáticos, la mediana general de la puntuación total de MeNTS fue 48 (RIC 44-52) y el promedio para IF-VIG fue de 0,0 (desviación estándar 0,1). Conclusiones: MeNTS, IF-VIG y Encuesta de síntomas, son escalas fácilmente accesibles durante tiempos de pandemia y son de utilidad para seleccionar pacientes de riesgo intermedio y bajo de morbilidad perioperatoria en cirugía electiva durante la pandemia por SARS-CoV-2. Se requieren futuros estudios para confirmar estos hallazgos y para clarificar su potencial en la selección de pacientes con criterios que los definan como de riesgo alto.

Laparoscopic Roux-en-Y gastric bypass in the treatment of obesity: evidence based update through randomized clinical trials and meta-analyses.

Bariatric surgery was introduced in 1953, but during the last 20 years its popularity has increased after the development of significant Romaevidenced based breakthroughs in the field. Currently, approximately 150 long-term randomized clinical trials and 40 meta-analyses support and give credibility to the surgical approaches for the treatment of obesity and its related metabolic disturbances. Bariatric surgery has demonstrated improved outcomes compared to medical treatment, conduct therapy, and endoscopic procedures. Roux-en-Y gastrojejunostomy (RYGB) and Sleeve gastrectomy (SG) are the surgical procedures most frequently performed, due to their satisfactory results and security profile. There is sufficient evidence in medical literature to perform these procedures when indicated; however, there are still several controversies regarding technical aspects that need to be further explored.

Brachial plexus tumors in a tertiary referral center: a case series and literature review.

INTRODUCTION: Brachial plexus (BP) tumors are very rare tumors, with less than 800 cases been described in the literature worldwide since 1970. These tumors often present as local or radicular pain, with scant or no neurological deficits. These symptoms are shared by many other more common rheumatologic diseases, thus making their diagnosis difficult in most cases. Additionally, these tumors often present as lumps and are therefore biopsied, which carries a significant risk of iatrogenic nerve injury. MATERIAL AND METHODS: In this paper the authors describe their experience with the management of 5 patients with BP tumors followed up for at least 2 years. There were 4 males and 1 female. Median follow-up time was 41 ± 21 months. Average age at diagnosis was 40,0 ± 19,9 years. The most common complaints at presentation were pain and sensibility changes. All patients had a positive Tinel sign when the lesion was percussed. In all patients surgery was undertaken and the tumors removed. In 4 patients nerve integrity was maintained. In one patient with excruciating pain a segment of the nerve had to be excised and the nerve defect was bridged with sural nerve grafts. RESULTS: Pathology examination of the resected specimens revealed a Schwannoma in 4 cases and a neurofibroma in the patient submitted to segmental nerve resection. Two years postoperatively, no recurrences were observed. All patients revealed clinical improvement. The patient submitted to nerve resection had improvement in pain, but presented diminished strength and sensibility in the involved nerve territory. CONCLUSION: Surgical excision of BP tumors is not a risk free procedure. Most authors suggest surgery if the lesion is symptomatic or progressing in size. If the tumor is stationary and not associated with neurological dysfunction a conservative approach should be taken.

Traumatismo herniarios, otro riesgo de una hernia no reparada / Hernia trauma, risks of unrepaired hernia

Las perforaciones intestinales asociadas a traumatismos herniarios han sido descritas en contadas ocasiones. Describimos 2 casos de pacientes con hernias no reparadas que sufren traumatismo herniario romo y asocian perforación colónica. Señalamos así otro riesgo de dejar una hernia inguinal sin reparar (independiente de la incarceración y la estrangulación)

There are few case reports in literature that describe bowel perforation after blunt hernia trauma. We describe 2 cases of blunt hernia trauma with colonic perforation. These cases point out another risk of leaving an inguinal hernia unrepaired, apart from incarceration and strangulation of intra-abdominal structures

Uso de segmentos intestinales en urología: seguimiento a 5 años / Use of intestinal segments im urology: a 5-year follow-up

Introducción: Desde hace más de 50 años se utilizan segmentos intestinales en urología para aumentar o reemplazar vejigas, reemplazar uréteres y derivar la orina a través de segmentos de intestino aislados. Objetivo: Describir la casuística de cirugías con uso de segmentos intestinales y a los menos 5 años de seguimiento completo, realizada en el Servicio de Urología del HCVB, sus principales indicaciones, técnicas y complicaciones. Materiales y métodos: Estudio observacional retrospectivo. Se revisaron 291 fichas de pacientes operados con uso de un segmento intestinal, con más de 5 años de seguimiento posterior, evaluando diagnóstico etiológico, técnica utilizada para enterocistoplastia, reservorio, neoimplante, ostomía y sus respectivas complicaciones a 3 meses, 5 años y final de seguimiento. Resultados: Se efectuaron 301 intervenciones (291 pacientes + 10 reinterveciones con uso de nuevos segmentos intestinales). Se seleccionan 111 casos (36,8 por ciento) en los que se dispone de seguimiento superior a 5 años. La principal indicación fue hiperactividad neurogénica del detrusor con 39 casos (35,14 por ciento); 30 casos (27,03 por ciento) de cistopatía intersticial; 16 casos (14,41 por ciento) de cáncer vesical; 11 casos (9,91 por ciento) de vejiga hiperactiva idiopática. Del total 70 fueron mujeres (63,06 por ciento), 41 fueron hombres (36,94 por ciento). La intervención más frecuente es la enterocistoplastia detubulizada de ampliación (79,28 por ciento), seguido por el reservorio ortotópico (10,9 por ciento). La elección del segmento intestinal se basó principalmente en la factibilidad anatómica, el íleon detubulizado en parche en U a la cara posterior para las enterocistoplastias de ampliación y el uso de segmentos de intestino grueso para fabricaciones deostomías continentes.La mayor cantidad de complicaciones se presenta en el periodo entre los 3 meses y 5 años de seguimiento (23 de 111 casos)

Introduction: Since over 50 years intestinal segments have been used in urology to augment or replace bladders, ureters and divert urine through isolated intestinal segments. Objective: The purpose of this article is to describe the use of intestinal segments in urological surgeries performed in the urological service of the HCVB, with a minimum of 5 years of follow-up. Indication, technique and complications are analyzed. Materials ad methods: It is an observational and retrospective study. 291 clinical charts of patients with use of intestinal segments in their surgery and more than 5 years of follow-up were analyzed. We evaluated diagnosis, technique used for bladder augmentation, reservoir, neoimplantation, stoma and their complications at a 3rd month, 5th year and end to follow-up moments. Results: A total of 301 surgeries were performed (291 patients + 10 revisions with use of new intestinal segments). 111 cases (36,8 percent) had a 5-year follow-up. Main indication for surgery was neurogenic detrusor hiperactivity in 39 cases (35,14 percent); there were 30 interstitial cystitis cases (27,03 percent); 16 cases ob bladder cancer (14,41 percent); 11 cases of idiopathic hyperactive bladder (9,91 percent). From the total group70 (63,06 percent) were female and 41 (36,94 percent) male. The most frequent surgery performed was the detubularized bladder augmentation (79,28 percent), followed by the orthotopic reservoir (19,9 percent).Election of the intestinal segment was based principally in technical feasibility, U-shaped detubularized ileum as a posterior patch for bladder augmentations and colon for continent stomas. Most complications occur between the 3rd month and the 5th year of follow-up (23 of 111 cases), needing non- surgical treatment in 12 cases, surgery in 6 cases and 3 patients stood in a life-risk situation. Continence is good in 88,7 percent of the cases. Conclusions: The use of intestinal segments for patch, reservoir and

Ostomías continentes para cateterismo intermitente: experiencia del Hospital Carlos van Buren / Continent stomas for intermittent catheterization: Hospital Carlos van Buren’s experience

Introducción: Existen situaciones en la práctica urológica, en que el daño al aparato esfinteriano, uretra o vejiga obliga a recurrir a algún mecanismo que permita derivar un reservorio o vejiga ampliada hacia la pared abdominal. Para estos fines es posible realizar ostomías continentes, con distintos segmentos intestinales, para autocateterismo intermitente limpio. Objetivo: Describir la experiencia con distintas técnicas de ostomía continente para cateterismo intermitente limpio, su evolución a través del tiempo y sus principales complicaciones según la casuística del Servicio de Urología del Hospital Carlos Van Buren. Materiales y Método: Estudio observacional retrospectivo. Revisión de 77 casos en los cuales se realizan ostomías continentes para cateterismo intermitente desde julio de 1988 a junio de 2009. Se evalúan: diagnóstico etiológico, técnica de ostomía, segmento intestinal, ubicación de extremo distal de ostomía y sus respectivas complicaciones precoces, tardías y estado al final del seguimiento. Resultado: En 83 ocasiones hemos necesitado hacer alguna derivación urinaria vesical continente a la pared abdominal con uso de segmentos intestinales. En 26 casos (31,3 por ciento) utilizamos íleon aplicado más alguna variedad que le permita cierta fijación. En nuestros últimos 33 (39,7 por ciento) pacientes hemos realizado la técnica de Yang-Monti, para ello se utilizó segmentos de intestino grueso en 27 casos (81,82 por ciento). La mayor cantidad de complicaciones de resolución quirúrgica (38,6 por ciento del total), se presentan en el periodo de 3 meses a 5 años; a su vez las complicaciones más graves lo hacen en el postoperatorio inmediato, en pacientes con baja reserva funcional (6 de 77) con 4 muertes en nuestra serie. La continencia es cercana al 100 por ciento, con 19,48 por ciento de reintervenciones de la ostomía para lograr este resultado. Conclusiones: El uso de ostomías continentes permite alcanzar un alto porcentaje de continencia

Introduction: There are situations in urologic practice, in which the damage to the sphincter, urethra or bladder forces to build some mechanism that allows diverting urine through a reservoir or augmented bladder towards the abdominal wall. For these purposes it is possible to build continent stomas, with different intestinal segments, for clean intermittent catheterization. Objective: To describe the Hospital Carlos van Buren’s experience with different continent stoma techniques for clean intermittent catheterization, its evolution through time and its main complications. Materials and Method: Retrospective observational study. From July 1988 to June 2009, 77 cases in which continent stomas for intermittent catheterization were built. Etiologic diagnosis, surgical technique, intestinal segment, location of distal end of the stoma and its respective early and delayed complications and status at the end of follow-up are evaluated. Results: In 83 occasions we have needed to make some continent urinary diversion to the abdominal wall with use of intestinal segments. In 26 cases (31.3 percent) we used folded ileum plus some variety of fixations. In our last 33 (39.7 percent) patients we have used the Yang-Monti technique, and for that we used thick bowel in 27 cases (81.82 percent).Most complications of surgical resolution (38.6 percent of the total), appeared in the 3 months to 5 years period; most serious complications appeared in the early post-operative period, in patients with low functional reserve (6 of 77) with four deaths in the series. Continence is almost 100 percent, with 19.48 percent of stomal re-interventions to obtain these results. Conclusions: The use of continent stomas allows a high percentage of continence. This allows self standing patients, with a positive impact on their quality of life when compared to incontinent stomas

Hiperactividad neurogénica del detrusor refractaria a tratamiento conservador: experiencia con el uso de segmentos intestinales / Neurogenic detrusor over activity refractory to conservative treatment: experience using intestinal segments

A pesar de la gran variedad de terapias descritas para el manejo de hiperactividad neurogénica del detrusor (HND), existe un número importante de pacientes que no logran mejoría con alternativas conservadoras. En ellos, bajar la presión y disminuir el porcentaje de daño renal mediante ampliación vesical con segmentos intestinales detubulizados, es una alternativa vigente. Objetivo: Describir la experiencia en el manejo de pacientes con HND refractaria a tratamiento conservador, que fueron tratados en forma quirúrgica con técnicas que utilizan segmentos intestinales, su evolución a través del tiempo y sus principales complicaciones. Materiales y métodos: Se revisaron fichas clínicas de 75 pacientes con diagnóstico de HND, operadas de enterocistoplastia entre 1988 y 2009. Se analizan: causa de daño neurológico, segmentos intestinales usados, técnica quirúrgica, necesidad de ostomía continente y complicaciones. Resultados: La serie estudiada está compuesta por 46 (61,33 por ciento) varones y 29 (38,67 por ciento) mujeres, con edad promedio 32,2 años (2,75 a 68 años). Las principales causas de daño neurológico fueron traumatismo raquimedular en 37 pacientes (49,43 por ciento) y mielomeningocele en 15 pacientes (20 por ciento). En total se realizaron 81 cirugías con uso de intestino: 6 corresponden a reintervenciones (3 ampliaciones con cierre de cuello y ostomía y 3 ostomías). De las 75 cirugías primarias se realizaron73 (97,33 por ciento) enterocistoplastias de aumento (en el 40 por ciento de los casos asociado a una ostomía continente), 1 cirugía de solamente ostomía continente y 1 reservorio. El segmento intestinal más utilizado para ampliación fue sigmoides; en los casos de ampliación y ostomía se prefirió ciego-íleon. La tendencia en los últimos 15 pacientes, es realizar la ostomía con técnica de Yang- Monti con colon o con doble segmento de íleon. El 30 por ciento de los pacientes requirió algún tipo de revisión quirúrgica en el...

Despite the wide variety of therapies described for the management of neurogenic detrusor over activity (NDH), a significant number of patients fail to improve with conservative treatment. In them, lowering pressure and decreasing the percentage of kidney damage by bladder augmentation with intestinal segments is a valid alternative. Objective: To describe the experience in the management of patients with NDH refractory to conservative treatment that were treated surgically with techniques using intestinal segments, their evolution over time and common complications. Materials and methods: We reviewed medical records of 75 patients with NDH with enterocystoplasty surgery between 1988 and 2009. We assessed: cause of neurological damage, intestinal segments used, surgical technique, need for continent ostomy and complications. Results: The studied group consists of 46 (61.33 percent) males and 29 (38.67 percent) females, mean age 32.2 years (2.75 to 68). The main causes of neurological damage were spinal cord injury in 37 patients (49.43 percent) and myelomeningocele in 15 patients (20 percent). A total of 81 surgeries using bowel were performed: 6 correspond to re-intervention (3 extensions with neck closure and ostomy; and 3 ostomies). Of the 75 primary surgeries, 73 (97.33 percent) were enlargement enterocystoplasty (in 40 percent of cases associated with a continent ostomy), 1 contienent ostomy surgery alone and 1 reservoir. The most widely used bowel segment for enlargement was sigmoid, in cases of expansion and ostomy a cecum-ileum segment was preferred. The trend in the last 15 patients was to perform an ostomy with Yang-Monti technique using colon or ileal double segment. On follow up over 5 years, 30 percent of the patients required some type of surgical revision and their main indications were incontinence, impaired opening of the bladder neck, urethral lithiasis and stenosis. Continence was good in 90.67 percent and 5.33 percent average...

Micción obstructiva posterior a cinta suburetral: manejo sin uretrólisis regulando la malla de acuerdo a presión de escape intraoperatorio / Obstructive micturiction posterior to suburethral sling: management of urethrolysis according to intraoperative leak pressure

Introducción: La micción obstructiva es complicación frecuente posterior a la cirugía para incontinencia de orina con cinta suburetral. El tratamiento convencional de la presentación tardía es la uretrólisis por vía abdominal o vaginal. Ésta técnica corresponde a una cirugía invasiva, que puede requerir varios procedimientos y a nuestro parecer, no se relaciona con la patogenia de la disfunción miccional postoperatoria. Objetivos: Describir el manejo quirúrgico de pacientes con micción obstructiva posterior a cinta suburetral, sin uretrólisis, con sección de la cinta y disminuyendo la presión de escape intraoperatoria (PE-IO). Además mostrar los resultados obtenidos con su aplicación en el Hospital Carlos Van Buren. Material y métodos: De 1.240 cirugías con cinta suburetral, se consideraron obstructivas las pacientes que presentaron síntomas irritativos más uruflujometría patológica con residuo posmiccional (RPM) elevado o estudio flujo/presión obstructivo. Con anestesia espinal se seccionó la malla suburetral y se descendió la uretra hasta alcanzar un escape con Valsalva de 35 cm de agua. Se evalúan datos como mejoría sintomática, uroflujometría, RPM y estudio flujo/presión. Resultados: Se describen los resultados de 12 pacientes: 7 TVT y 5 TOT. Todas consultaron por síntomas de disfunción miccional y en el 100 por ciento se objetivó uropatía obstructiva previo a la segunda cirugía. Con anestesia espinal y vejiga llena con 300 cc, 4 presentaron escape sobre 60 cm de agua y 8 sobre 80 cm de agua. Una vez seccionada la malla se ajusta para PE-IO de 35 cm de agua. Se obtuvo mejoría clínica y urodinámica en el 100 por ciento de los casos que completaron seguimiento (11/12). Conclusiones: Las pacientes obstructivas posterior a cinta suburetral, presentan presión de escape intraoperatorio elevado (bajo anestesia espinal). La regulación de tensión de la cinta suburetral para obtener escape con Valsalva a 35 cm de agua, permite...

Introduction: Obstructive micturition (OM) is a frequent complication after suburethral sling (SL) placement for urinary incontinence. Abdominal or vaginal urethrolysis is the preferred treatment, however this invasive technique may require several attempts and it is our belief that this does not relate to postoperative urinary dysfunction. Objective: To describe surgical management of patients with OM secondary to SL without urethrolysis, by performing a sling section and decreasing intraoperative leak pressure (IOLP) at our institution. Material and methods: Of 1240 patients with SL, OM was considered to be present if voiding symptoms along with obstructive flowmetry and elevated urinary residue was found. SL is sectioned under spinal anaesthesia and the urethra is descended until a 35 cm water valsalva leak pressure is achieved. Symptoms along with flowmetry and residual urine were evaluated. Results: We present results of 12 patients: 7 TVT and 5 TOT. All were seen with urinary dysfunction and in all patients obstructive micturiction before the second surgery. Under spinal anaesthesia and with a bladder filled with 300 cc, 4 patients leaked with 60 cm and 8 with 80 cm of water pressure. Once the sling was sectioned it was adjusted to an IOLP of 35 cm of water. Symptoms and urodynamic studies showed recovery (11/12). Conclusion: Patients with OM alter SL showed high IOLP. Sling adjustment for a 35 cm water valsalva leak pressure delivers good postoperative results. SL section is an adequate treatment for these patients, urethrolysis seems questionable.

Sildenafil citrate and Torsade de pointes

Sildenafil citrate is a drug used in the treatment of erectile dysfunction. It is an inhibitor of the enzyme phosphordiesterase-5; it slows down the breakdown of c-GMP and nitrous oxide. The cardiac effects associated with Sildenafil citrate have been extensively studied in medical literature, especially its potent vasodilatory effect when combined with nitrate-based medications, producing intractable hypotension, but a lesser known and potentially lethal side effect is prolonged cardiac repolarization when used at dosage greater than recommended, leading to QT prolongation that could theoretically lead to dangerous cardiac dysrrhythmias and sudden death in men with coronary artery disease. The authors present the case of a 49-year-old hypertensive Hispanic man who arrived to our emergency department with the chief complaint of acute epigastric pain for 3 hours of evolution after ingestion of Sildenafil citrate 50 milligrams (mg). The patient was found to have an acute ST elevation inferior myocardial infarction (STEMI). Shortly after diagnosis the patient developed a polymorphic ventricular tachycardia (Torsade de pointes) before thrombolytic administration. We present this case followed by a brief discussion, to heighten awareness of the possible association of acute inferior STEMI and the development of Torsade de Pointes after the use of Sildenafil citrate.

Listeriosis: una infección poco frecuente en pacientes con VIH / Listeriosis: an infrequent infection in patients with HIV

Aunque la resistencia a la infección por Listeria monocytogenes requiere que la inmunidad celular este indemne, la listeriosis es una enfermedad poco frecuente en los pacientes VIH+ y existen únicamente alrededor de unos 50 casos publicados. Se presentan los dos únicos enfermos VIH+ con infección por L. monocytogenes atendidos en nuestro hospital desde el inicio de la epidemia del sida en 1981. Caso 1: Varón VIH+ con 364 linfocitos CD4+ por mm3 que ingresó por cefalea occipital y fiebre. La tomografía axial computarizada cerebral fue normal y en el cultivo del líquido cefalorraquídeo creció L. monocytogenes. Se trató favorablemente con ampicilina y tobramicina. Caso 2: Varón de 47 años VIH+ con 44 linfocitos CD4+/ mm3 y cirrosis hepática por VHC que ingresó por fiebre elevada y distensión abdominal. Realizaba profilaxis para PCP con pentamidina IV. Con el diagnóstico de peritonitis bacteriana espontánea se extrajeron 3 hemocultivos y se inició tratamiento con ceftriaxona. Desarrolló encefalopatía hepática y falleció a las 72 h del ingreso. Postmortem se recibió crecimiento de L. monocytogenes. La listeriosis es una enfermedad poco frecuente en los enfermos VIH+, que esporádicamente produce cuadros de difícil diagnóstico, sobre todo en los enfermos que no realizan profilaxis para PCP con cotrimoxazol (AU)

[Pulmonary hypertension in patients with human immunodeficiency virus infection. Study of 14 cases]. / Hipertensión pulmonar en los pacientes con infección por el virus de la inmunodeficiencia humana. Estudio de 14 casos.

BACKGROUND: There have been several reports describing PAH and cor pulmonary in HIV infected patients like observed in patients with primary PAH. PATIENTS AND METHODS: We retrospectively studied 14 patients with HIV infection and PH documented by Doppler echocardiography diagnosed during the last 9 years (1991-1999). RESULTS: The mean length of time from the onset of symptoms to the diagnosis was 4 months (r: 1 week-1 year). PAH was diagnosed as mild in 3 cases (23%), moderate in 7 (54%) and severe in 4 and the mean value of right ventricular systolic pressure was 57.96 mmHg. Ten patients were conventionally treated and in 5 cases progressive right sided heart failure was developed. In this group, carvedilol was prescribed with a favourable evolution in four of them. Three cases did not required treatment. All the patients were followed for 2 years (r: 1-8) and three deaths happened (22%). CONCLUSIONS: The grade of PH in patients with HIV is moderate-severe, the time between onset of symptoms and diagnosis is very long but survival is not poor. Carvedilol could be an alternative therapy in patients who dose responses to another treatments and with progressive right heart failure.

[Listeriosis: an infrequent infection in patients with HIV]. / Listeriosis: una infección poco frecuente en pacientes con VIH.

Although resistance to Listeria monocytogenes infection requires intact T-cell mediated immunity, listeriosis is an infrequent problem in patients with HIV infection and only about 50 patients have been reported to date. Only two patients with HIV and L. monocytogenes have been attended in our hospital since the beginning of aids epidemic in 1981. Case 1: a man with HIV and 364 CD4+ cells/mm3 presented fever and occipital headache. The cerebral scan was normal and L. monocytogenes grew in licuor culture. He was outcome after treatment with ampicillin and tobramycin. Case 2: a 47 years old man with HIV, 44 CD4+ cells/mm3 and hepatic virus C cirrhosis was admitted to the hospital because fever and abdominal distension. He was on menstrual pentamidine prophylaxis for Pneumocystis carinii pneumonia (PCP). Bacterial peritonitis was diagnosed and the patient begun treatment with ceftriaxone. The patient dead 72 hours later with hepatic encepholopathy. Postmortem L. monocytogenes grew. Listeriosis is an infrequent disease in patients with HIV that causes difficult diagnostic problems, principally in patients without prophylaxis with cotrimoxazole for PCP.

Experiencia en ostomías con cirugía intestinal / Experience in ostomies with intestinal surgery

Entre julio de 1988 y mayo de 1996 hemos realizado en 59 casos intervenciones con alguna derivación urinaria. La denominamos artificial, en el caso de comunicar al exterior un reservorio o una ampliación vesical con o sin cierre de cuello; o natural, si la derivación se realiza al intestino con un ostoma como el ano. Se analizan las indicaciones, los tipos de intervenciones asociadas y las complicaciones. En 46 casos (78 por ciento) fue ostomía artificial y en 13 casos (22 por ciento) ostomía natural. En los ostomas artificiales analizamos las diferentes variedades de ostomías. Un (56,5 por ciento) corresponde a ileon plicado más alguna variedad que le permita cierta fijación. En los ostomas artificiales hemos logrado una incidencia en los casos controlados de 100 por ciento de continencia; tenemos 7 casos de revisiones de la ostomía para lograr estos resultados. Todos los casos de ostomías naturales corresponden a cánceres de vejiga (generalmente avanzados), o a pacientes rurales de los que tenemos pocas evoluciones por pérdida de control o fallecimientos

[Imaging in atherosclerosis: coronary arteriography]. / Imaging nell'aterosclerosi: arteriografia coronarica.

Arteriography is still today the best imaging technique to evaluate coronary atherosclerosis. Some limitations have nonetheless been documented by pathologic studies (underestimated lesions), and by physiologic studies (poor correlation between stenosis and coronary flow reserve). Such limitations are due to the nature of the technique, as it provides the "silhouette" of the artery lumen, but does not provide any information on the artery wall, where the atherosclerotic plaque is located. Moreover, very often the vessel segment used as reference for stenosis calculation could also be affected by atherosclerosis; this occurrence plagues measurement of percent stenosis. On the other hand, a better usage of radiological techniques has also allowed a better assessment of certain stenosis shapes, such as eccentric or slit-like lesions. The introduction of quantitative coronary arteriography has overcome the problems related to visual assessment, such as the inter and intra observer variability. Furthermore, the recognized value of morphology analysis allows today a better characterization of the lesion. Coronary arteriography remains today a non-replaceable technique with regard to the choice of the most suitable revascularization procedures (coronary artery bypass graft, percutaneous transluminal coronary angioplasty) and supplies fundamental information for the interventional procedures.

[Mitral valvuloplasty: immediate results and 2-year follow-up]. / La valvuloplastica mitralica: risultati immediati e follow-up a 2 anni.

Since May 1991 to July 1993, 121 patients (mean age 50 +/- 13 years, 23 males and 98 females) underwent 122 percutaneous mitral valvuloplasty according to Inoue's technique. Following Wilkins criteria the indications for the procedure were given on the basis of the echo-score (ideal cases with score < or = 8). Echo-score was > 8 in 59 patients (49%), and < or = 8 in 62 (51%); 19 patients (16%) had previous surgical mitral commissurotomy and 36 (30%) had previous embolic events. All patients were successfully treated except for 5 who developed mitral regurgitation 3+/4+. In 1 patient the procedure was unsuccessfully performed for the low increase in mitral valve area. All these patients except 1 were referred to elective surgery. Mitral valve area increased from 1.1 +/- 0.2 to 2.1 +/- 0.4 cm2 (p < 0.001) and transvalvular gradient fell from 15 +/- 6 to 6 +/- 3 mmHg (p < 0.001). Patients with previous surgical commissurotomy had a lower increase in the mitral valve area than patients without previous surgery (p < 0.006). Patients with echo-score > 8 presented a lower, but not significant, increase in mitral valve area after valvuloplasty; patients with mono-commissural calcifications had worse results than those without calcifications (p < 0.03). At 12 and 24 month follow-up 9 and 3 restenosis respectively occurred, but in 10 of these cases the residual valvular area was > 1.5 cm2. The Authors conclude that in patients with good anatomy percutaneous mitral valvuloplasty is an effective and safe treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of 6 and 8 French catheters for arterial catheterization and coronarography: prospects of the development of coronarography in ambulatory care]. / Confronto fra cateteri 6 ed 8 French per cateterismo arterioso e coronarografia: prospettive di sviluppo della coronarografia in regime ambulatoriale.

The aim of this study was to evaluate day-hospital coronary angiography as a valid method to reduce hospital recovery costs and patient waiting lists. We evaluated its technical feasibility by randomizing sixty hospital patients. These were divided into two groups, and 6 or 8 French Judkins of Amplatz coronary angiography catheters were used for each group following the Judkins technique. Patients were invited to walk after four hours. Local complications, the number of catheters used, their stability and maneuverability, as well as the radiological resolution of the image were evaluated. No major cardiac complications occurred. One transient cerebral ischemic episode during 6F coronary angiography was quickly resolved by medical therapy. Two local haemorrhages and three cases of hypotension were observed in the 8 French group, while minor bleeding phenomena were similar in both groups (3 vs 5). Differences occurred in local haematoma incidence after 24 hours (13 in 8F vs 2 in 6F); there was no difference in the number of catheters used, the completion time of the examination, or the radiological resolution. Maneuverability and stability of the 6F group were reduced, but not so much as to compromise examination. The AA concluded that 6F catheters are useful in day-hospital coronary angiography, with a similar examination quality, and a reduction in local complication.