Reprogramming human B cells into induced pluripotent stem cells and its enhancement by C/EBPα.

B cells have been shown to be refractory to reprogramming and B-cell-derived induced pluripotent stem cells (iPSC) have only been generated from murine B cells engineered to carry doxycycline-inducible Oct4, Sox2, Klf4 and Myc (OSKM) cassette in every tissue and from EBV/SV40LT-immortalized lymphoblastoid cell lines. Here, we show for the first time that freshly isolated non-cultured human cord blood (CB)- and peripheral blood (PB)-derived CD19+CD20+ B cells can be reprogrammed to iPSCs carrying complete VDJH immunoglobulin (Ig) gene monoclonal rearrangements using non-integrative tetracistronic, but not monocistronic, OSKM-expressing Sendai Virus. Co-expression of C/EBPα with OSKM facilitates iPSC generation from both CB- and PB-derived B cells. We also demonstrate that myeloid cells are much easier to reprogram than B and T lymphocytes. Differentiation potential back into the cell type of their origin of B-cell-, T-cell-, myeloid- and fibroblast-iPSCs is not skewed, suggesting that their differentiation does not seem influenced by 'epigenetic memory'. Our data reflect the actual cell-autonomous reprogramming capacity of human primary B cells because biased reprogramming was avoided by using freshly isolated primary cells, not exposed to cytokine cocktails favoring proliferation, differentiation or survival. The ability to reprogram CB/PB-derived primary human B cells offers an unprecedented opportunity for studying developmental B lymphopoiesis and modeling B-cell malignancies.

[Improving the outcomes in spontaneous subarachnoid haemorrhage: the EHSA project]. / Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA.

AIM: To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgical management of spontaneous subarachnoid haemorrhages (SAH). PATIENTS AND METHODS A prospective, longitudinal cohort study was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 public hospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acute haemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medical and surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latter was then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due to rebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentially avoidable deaths. RESULTS: A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155 patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension, coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. CONCLUSIONS: Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors.

Mejora de los resultados en la hemorragia subaracnoidea espontánea: proyecto EHSA / Improving the outcomes in spontaneous subarachnoid haemorrhage: The Ehsa project

Objetivo. Investigar nuestras prácticas clínicas, a fin de identificar oportunidades de mejora en el manejo medicoquirúrgicode las hemorragias subaracnoideas (HSA) espontáneas. Pacientes y métodos. Estudio de cohortes, longitudinal,prospectivo, de las HSA atendidas consecutivamente en los servicios de cuidados críticos y urgencias de 29 hospitales públicosde Andalucía durante 20 meses, de 2000 a 2002. Se consideraron HSA los accidentes cerebrovasculares hemorrágicosagudos con este diagnóstico tomográfico. Se analizaron los resultados a 12 meses y el manejo asistencial (terapéutica médicay quirúrgica, técnicas diagnósticas, tiempos asistenciales y complicaciones neurológicas específicas), comparándolo conlas prácticas clínicas que la evidencia científica ha demostrado de mayor utilidad. Se catalogaron como muertes potencialmenteevitables los óbitos por resangrado en pacientes sin estudio arteriográfico o sin exclusión del aneurisma. Resultados.Se incluyeron 506 HSA. Se perdió durante el seguimiento el 5% de la muestra. Fallecieron 155 enfermos. Las variables no modificablesde riesgo independiente para la mortalidad fueron: edad, género masculino, antecedente de hipertensión arterial,coma a la recepción hospitalaria e hidrocefalia. Las variables influenciables de riesgo independiente para fallecer resultaronser: ausencia de analgesia urgente, carencia de diagnóstico arteriográfico, aparición de deterioro neurológico isquémico yresangrado. El 20% de la mortalidad global podría considerarse potencialmente evitable. Conclusiones. Aunque la letalidades mayoritariamente dependiente de variables médicamente no influenciables (sexo, edad, antecedentes, gravedad clínica ehidrocefalia), los decesos, en un 20%, están asociados a factores modificables (AU)

Aim. To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgicalmanagement of spontaneous subarachnoid haemorrhages (SAH). Patients and methods. A prospective, longitudinal cohortstudy was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 publichospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acutehaemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medicaland surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latterwas then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due torebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentiallyavoidable deaths. Results. A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension,coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable. Conclusions. Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors (AU)

Mean lifetime and first-passage time of the enzyme species involved in an enzyme reaction. Application to unstable enzyme systems.

Taking as starting point the complete analysis of mean residence times in linear compartmental systems performed by Garcia-Meseguer et al. (Bull. Math. Biol. 65:279-308, 2003) as well as the fact that enzyme systems, in which the interconversions between the different enzyme species involved are of first or pseudofirst order, act as linear compartmental systems, we hereby carry out a complete analysis of the mean lifetime that the enzyme molecules spend as part of the enzyme species, forms, or groups involved in an enzyme reaction mechanism. The formulas to evaluate these times are given as a function of the individual rate constants and the initial concentrations of the involved species at the onset of the reaction. We apply the results to unstable enzyme systems and support the results by using a concrete example of such systems. The practicality of obtaining the mean times and their possible application in a kinetic data analysis is discussed.

[Safety and efficacy of the MARS therapy applied by continuous renal replacement therapy (CRRT) monitors]. / Seguridad y eficacia de la terapia MARS aplicada mediante monitores de TCRR.

OBJECTIVE: Analyze the utility and safety of MARS therapy applied with the CRRT monitor. DESIGN: Prospective study of cohorts. SCOPE: Polyvalent ICU in tertiary university hospital with hepatic transplantation program. PATIENTS: Thirty one patients: 9 (22.6%) with acute liver failure (ALF) (1 hepatic surgery, 1 primary graft failure, 7 other causes) and 22 (71%) with acute-on-chronic failure (AoCLF). INTERVENTIONS: For the treatment, the patients with ALF are maintained in the ICU but those with AoCLF are admitted for the performance of the different sessions, that are programmed for a duration of at least 15 hours in AoCLF and in ALF are maintained continuously, changing the circuit every 24 hours. VARIABLES OF INTEREST: Metabolic control and complications registered in 75 sessions on 31 patients. RESULTS: Urea decrease was 33.5 (29-38%), creatinine 36 (31-41%), total bilirubin 29 (25-33%) and direct bilirubin 34 (30-38%). Clearance was slower, but sustained, after the first 4 hours of each session both for urea (p<0.001) as well as for bilirubin (p<0.05). The hemodynamic parameters improved and the hematological ones were not altered. We detected decrease in platelets (131 to 120x109/L, p<0.01). In 95 of the sessions in which heparin was used and in 6% where epoprostenol was used, we observed mild bleeding. We cultured albumin of the circuit at the end of the session in 50 occasions and only obtained growth in 3 cases (6%) (2 Staphylococcus epidermidis, 1 S. haemolyticus) without signs of contamination in the patients. CONCLUSIONS: The MARS system applied by CRRT monitors provide adequate bilirubin clearance percentages and is safe, even in serious patients. Prolongation of the duration of the sessions was not accompanied by an increase in the risk of infection secondary to the albumin contamination.

Seguridad y eficacia de la terapia MARS aplicada mediante monitores de TCRR / Safety and efficacy of the MARS therapy applied by continuous renal replacement therapy (CRRT) monitors

Objetivo. Analizar la utilidad y seguridad de la terapia MARS aplicada mediante un monitor de TCRR. Diseño. Estudio de cohortes prospectivo. Ámbito. Unidad de Cuidados Intensivos (UCI) polivalente en un hospital universitario de tercer nivel con programa de trasplante hepático. Pacientes. Treinta y un pacientes: 9 (22,6%) con fracaso hepático agudo (FHA) (un paciente con cirugía hepática, otro con fallo primario de injerto y 7 con otras causas) y 22 (71%) con fracaso agudo sobre crónico (FHAsC). Intervenciones. Para el tratamiento los pacientes con FHA son mantenidos en la UCI, pero los FHAsC son admitidos para la realización de las diferentes sesiones, que se programan para una duración de al menos 15 horas en FHAsC y en FHA se mantienen de forma continuada cambiando el circuito cada 24 horas. Variables de interés. Control metabólico y complicaciones registradas en 76 sesiones sobre los 31 pacientes. Resultados. La disminución de urea fue 33,5 (29-38%), creatinina 36 (31-41%), bilirrubina total 29 (25-33%) y directa 34 (30-38%). La eliminación fue mas lenta pero sostenida tras las primeras 4 horas de cada sesión tanto para la urea (p < 0,001) como para la bilirrubina (p < 0,05). Los parámetros hemodinámicos mejoraron y los hematológicos no se alteraron. Detectamos descenso de plaquetas (131 a 120 x109/l, p < 0,01). En el 9% de las sesiones en que se usó heparina, y en el 6% de las que se utilizó epoprostenol observamos sangrado leve. Hemos cultivado la albúmina del circuito al final de la sesión en 50 ocasiones y sólo obtuvimos crecimiento en tres casos (6%) (dos Staphylococcus epidermidis y un S. haemolyticus) sin signos de contaminación en los pacientes. Conclusiones. El sistema MARS aplicado mediante monitores para TCRR proporciona porcentajes de eliminación de bilirrubina adecuados y es seguro incluso en pacientes graves. La prolongación de la duración de las sesiones no se ha acompañado de un incremento del riesgo de infección secundaria a la contaminación de la albúmina

Objective. Analyze the utility and safety of MARS therapy applied with the CRRT monitor. Design. Prospective study of cohorts. Scope. Polyvalent ICU in tertiary university hospital with hepatic transplantation program. Patients. Thirty one patients: 9 (22.6%) with acute liver failure (ALF) (1 hepatic surgery, 1 primary graft failure, 7 other causes) and 22 (71%) with acute-on-chronic failure (AoCLF). Interventions. For the treatment, the patients with ALF are maintained in the ICU but those with AoCLF are admitted for the performance of the different sessions, that are programmed for a duration of at least 15 hours in AoCLF and in ALF are maintained continuously, changing the circuit every 24 hours. Variables of interest. Metabolic control and complications registered in 75 sessions on 31 patients. Results. Urea decrease was 33.5 (29-38%), creatinine 36 (31-41%), total bilirubin 29 (25-33%) and direct bilirubin 34 (30-38%). Clearance was slower, but sustained, after the first 4 hours of each session both for urea (p < 0.001) as well as for bilirubin (p < 0.05). The hemodynamic parameters improved and the hematological ones were not altered. We detected decrease in platelets (131 to 120 x109/L, p < 0.01). In 95 of the sessions in which heparin was used and in 6% where epoprostenol was used, we observed mild bleeding. We cultured albumin of the circuit at the end of the session in 50 occasions and only obtained growth in 3 cases (6%) (2 Staphylococcus epidermidis, 1 S. haemolyticus) without signes of contamination in the patients. Conclusions. The MARS system applied by CRRT monitors provide adequate bilirubin clearance percentages and is safe, even in serious patients. Prolongation of the duration of the sessions was not accompanied by an increase in the risk of infection secondary to the albumin contamination

Kinetic analysis of a general model of activation of aspartic proteinase zymogens involving a reversible inhibitor. I. Kinetic analysis.

Starting from a simple general reaction mechanism of activation of aspartic proteinases zymogens involving a uni- and a bimolecular simultaneous activation route and a reversible inhibition step, the time course equation of the zymogen, inhibitor and activated enzyme concentrations have been derived. Likewise, expressions for the time required for any reaction progress and the corresponding mean activation rates as well as the half-life of the global zymogen activation have been derived. An experimental design and kinetic data analysis is suggested to estimate the kinetic parameters involved in the reaction mechanism proposed.

Kinetic analysis of a general model of activation of aspartic proteinase zymogens involving a reversible inhibitor. II. Contribution of the uni- and bimolecular activation routes.

From the kinetic study carried out in part I of this series (preceding article) an analysis quantifying the relative contribution to the global process of the uni- and bimolecular routes has been carried out. This analysis suggests a way to predict the time course of the relative contribution as well as the effect on this relative weight of the initial zymogen, inhibitor and activating enzyme concentrations.

[Dysautonomic seizures in patients admitted to an intensive care unit following severe traumatic brain injury]. / Crisis disautonómicas en pacientes ingresados en una unidad de cuidados intensivos tras un traumatismo craneoencefálico grave.

AIM: To describe clinical and radiologic features of dysautonomic crisis after severe traumatic brain injury and its influence in the clinical situation six months later. PATIENTS AND METHODS: Retrospective, observatory study of seven patients after severe head injury, with dysautonomic crisis, admitted in the Critical Care Unit (CCU) during six months. No interventions. Its clinical features, its association with intracranial pressure and the treatment for Dysautonomic crisis they have received were extracted from the computed clinical report. We have evaluated his neurologic prognosis with the Jennet-Bond scale and his radiologic characteristics with the Gennarelly scale. RESULTS: Dysautonomic crisis began in the first week if the patients didn't received neuromuscular blocks drugs and they continued when the patients were discharged from the CCU in a young population with an initial Glasgow scale coma of 5 points. We didn't wait a special radiologic pattern. After the next six months, crisis were disappeared in 86% of patients and all patients reached a good neurologic level in the Jennet-Bond scale. CONCLUSIONS: Dysautonomic crisis appeared early in young men after severe head injury. We didn't find a radiologic pattern that predisposes the dysautonomic crisis. They didn't interfere the recovering six months after head injury.

Crisis disautonómicas tras traumatismo craneoencefálico grave / Dysautonomic crises after serious head trauma

Algunos pacientes tras un traumatismo craneoencefálico grave sufren crisis disautonómicas, consistentes en episodios autolimitados de hipertensión arterial, taquicardia, taquipnea, hiperhidrosis, elevación de la temperatura corporal y dilatación pupilar, entre otros hallazgos. Presentamos una serie de tres pacientes con traumatismo craneoencefálico que desarrollaron tales crisis durante su estancia en la Unidad de Cuidados Intensivos (UCI). Describimos las manifestaciones clínicas de las crisis disautonómicas, los hallazgos de la tomografia axial computarizada de cráneo, y la situación funcional de los pacientes a los 6 meses del traumatismo. Los datos clínicos se extrajeron de la historia clínica informatizada de los pacientes. Los hallazgos radiológicos se evaluaron mediante la escala de Gennarelly, y el grado de recuperación neurológica a los 6 meses con la escala de Jennet y Bond, mediante entrevista telefónica (AU)

Crisis disautonómicas en pacientes ingresados en una unidad de cuidados intensivos tras un traumatismo craneoencefálico grave / Dysautonomic seizures in patients admitted to an intensive care unit following severe traumatic brain injury

Objetivo. Describir el perfil clínico de las crisis disautonómicas tras el traumatismo craneoencefálico (TCE) grave, los hallazgos radiológicos en los que se sustenta y la situación clínica de los pacientes a los seis meses de evolución. Pacientes y métodos. Se trata de un estudio de observación y retrospectivo de una serie de siete pacientes con TCE grave que presentaron crisis disautonómicas durante su estancia en la UCI, recogidos a lo largo de seis meses. No se realizó ninguna intervención. Las manifestaciones clínicas, su asociación con los valores de presión intracraneal, su persistencia al alta de la UCI y el tratamiento recibido se extrajeron de la historia clínica informatizada de los pacientes. El pronóstico neurológico a los seis meses se evaluó mediante entrevistas telefónicas utilizando la escala de Jennet y Bond, y los hallazgos radiológicos, mediante la escala de Gennarelly. Resultados. Las crisis disautonómicas se presentaron durante la primera semana de estancia y continuaron en el momento del alta de la UCI en una población joven, con un valor de la escala de Glasgow inicial de cinco puntos. No encontramos un patrón radiológico propio de los pacientes con crisis disautonómicas. A los seis meses habían desaparecido en el 86 por ciento de los casos, sin requerir una medicación específica, y todos alcanzaron un buen grado neurológico en la escala de Jennet y Bond. Conclusiones. Las crisis disautonómicas aparecieron precozmente en hombres jóvenes que sufrieron un TCE grave y no requirieron neurocirugía. No encontramos un patrón radiológico predisponente, ni su presencia interfirió con la recuperación neurológica a los seis meses de evolución (AU)

Aim. To describe clinical and radiologic features of dysautonomic crisis after severe traumatic brain injury and its influence in the clinical situation six months later. Patients and methods. Retrospective, observatory study of seven patients after severe head injury, with dysautonomic crisis, admitted in the Critical Care Unit (CCU) during six months. No interventions. Its clinical features, its association with intracranial pressure and the treatment for Dysautonomic crisis they have received were extracted from the computed clinical report. We have evaluated his neurologic prognosis with the Jennet-Bond scale and his radiologic characteristics with the Gennarelly scale. Results. Dysautonomic crisis began in the first week if the patients didn’t received neuromuscular blocks drugs and they continued when the patients were discharged from the CCU in a young population with an initial Glasgow scale coma of 5 points. We didn’t wait a special radiologic pattern. After the next six months, crisis were disappeared in 86% of patients and all patients reached a good neurologic level in the Jennet-Bond scale. Conclusions. Dysautonomic crisis appeared early in young men after severe head injury. We didn’t find a radiologic pattern that predisposes the dysautonomic crisis. They didn’t interfere the recovering six months after head injury (AU)

Mielinolisis central pontina en trasplante hepático / Central pontine myelinolysis in a liver transplant recipient

La mielinolisis central pontina es un síndrome conocido desde hace más de 4 décadas y primariamente descrito en pacientes alcohólicos, que consiste en una desmielinización de la sustancia blanca cerebral. Su mecanismo fisiopatológico se basa en los cambios osmóticos producidos en esta estructura al corregirse de forma brusca una hiponatremia preexistente. El paciente que se somete a un trasplante hepático es, en la mayoría de las ocasiones, un cirrótico previo y en muchos casos de origen alcohólico. La hiponatremia en este grupo es la regla; es de origen multifactorial y está fundamentalmente en relación con la terapia que se les aplica para el control de la ascitis. Debemos extremar nuestros cuidados en la corrección de esta hiponatremia en el período perioperatorio del trasplante y detectar de forma temprana las alteraciones de conciencia en el postoperatorio inmediato, que deben alertarnos del desarrollo de este síndrome (AU)

[The EHSA project: the study of spontaneous subarachnoid haemorrhages in Andalusia. Incidence and results]. / Proyecto EHSA: estudio de hemorragias subaracnoideas espontáneas en Andalucia. Incidencia y resultados.

AIM: To evaluate the incidence and results of spontaneous subarachnoid haemorrhages (SAH) in Andalusia. PATIENTS AND METHODS: We conducted a longitudinal prospective study of the cases of SAH attended in 28 hospitals in Andalusia over a three month period in 2000. SAH was defined as cases of acute haemorrhagic strokes diagnosed by tomography. The gross incidence rate (GR) was determined from census information from the Instituto Andaluz de Estad stica. Standard rates (SR) were estimated with relation to the European population. Results were evaluated on hospital discharge according to the Glasgow Outcome Score (GOS) and at 12 months, according the Barthel index (BI). RESULTS: The GR per 100,000 inhabitants/year was found to be 5.7 cases and the SR was 5.8. A comparison of incidences by province or sex showed no statistically significant differences. The period of maximum risk was the age bracket between 55 74 years (GR: 14.1). The acute fatality GR and SR rose to 1.9 per 100,000 inhabitants and year. Mortality was concentrated in a statistically significant way (p< 0.01) among those over the age of 65; sex did not exert any influence, but clinical gravity (p< 0.001) and the amount of bleeding did (p< 0.005). CONCLUSIONS: The incidence of spontaneous SAH in Andalusia was found to be within the average rates. Unfavourable results were high, although similar to those in other series. Fatality is significantly associated with factors that cannot be modified medically (age, clinical gravity and volume of bleeding)

Proyecto EHSA: estudio de hemorragias subaracnoideas espontáneas en Andalucía. Incidencia y resultados / The EHSA project: the study of spontaneous subarachnoid haemorrhages in Andalusia. Incidence and results

Objetivo. Valorar la incidencia y resultados de las hemorragias subaracnoideas (HSA) espontáneas en Andalucía. Pacientes y métodos. Estudio longitudinal, prospectivo, de las HSA asistidas en 28 hospitales de Andalucía, durante tres meses del año 2000. Se consideraron HSA los ictus hemorrágicos agudos con este diagnóstico tomográfico. La incidencia bruta (TB) se estableció mediante la información censal del Instituto Andaluz de Estadística. Las tasas estandarizadas (TEE) se estimaron con relación a la población europea. Los resultados se valoraron al alta hospitalaria según el GOS (del inglés, Glasgow Outcome Score) y a los 12 meses, según el índice de Barthel (IB). Resultados. La TB por 100.000 habitantes/año se situó en 5,7 casos y la TEE en 5,8. La comparación de incidencias según provincia o sexo no mostró diferencias estadísticamente significativas. El período de máximo riesgo corresponde al intervalo 55-74 años (TB: 14,1). La TB y TEE de letalidad aguda coincidió en 1,5. A los 12 meses, la TB y TEE de letalidad ascendió a 1,9 por 100.000 habitantes y año. La mortalidad se concentró de forma estadísticamente significativa (p< 0,01) entre los mayores de 65 años; no influyó el sexo, pero sí la gravedad clínica (p< 0,001) y la cuantía del sangrado (p< 0,005). Conclusiones. La incidencia de las HSA espontáneas en Andalucía se sitúa en tasas medias. La proporción de resultados desfavorables es elevada, aunque similar a la de otras series. La letalidad se asocia significativamente a factores (edad, gravedad clínica y volumen de sangrado) no modificables médicamente (AU)

Aim. To evaluate the incidence and results of spontaneous subarachnoid haemorrhages (SAH) in Andalusia. Patients and methods. We conducted a longitudinal prospective study of the cases of SAH attended in 28 hospitals in Andalusia over a threemonth period in 2000. SAH was defined as cases of acute haemorrhagic strokes diagnosed by tomography. The gross incidence rate (GR) was determined from census information from the Instituto Andaluz de Estadística. Standard rates (SR) were estimated with relation to the European population. Results were evaluated on hospital discharge according to the Glasgow Outcome Score (GOS) and at 12 months, according the Barthel index (BI). Results. The GR per 100,000 inhabitants/year was found to be 5.7 cases and the SR was 5.8. A comparison of incidences by province or sex showed no statistically significant differences. The period of maximum risk was the age bracket between 55-74 years (GR: 14.1). The acute fatality GR and SR rose to 1.9 per 100,000 inhabitants and year. Mortality was concentrated in a statistically significant way (p< 0.01) among those over the age of 65; sex did not exert any influence, but clinical gravity (p< 0.001) and the amount of bleeding did (p< 0.005). Conclusions. The incidence of spontaneous SAH in Andalusia was found to be within the average rates. Unfavourable results were high, although similar to those in other series. Fatality is significantly associated with factors that cannot be modified medically (age, clinical gravity and volume of bleeding) (AU)

Edema pulmonar agudo tras embolismo aéreo venoso central / Acute pulmonary edema after central venous air embolism

Se describe el caso de un paciente que desarrolló un edema pulmonar durante el período postoperatorio de una intervención de resección de neurinoma del nervio acústico, mediante craniectomía retromastoidea en posición sedente, en la que se produjo un embolismo aéreo venoso central (EAVC).El edema pulmonar secundario a EAVC, aunque descrito ocasionalmente, parece ser una constante según hallazgos experimentales y relacionado con la distribución de burbujas gaseosas en la microcirculación pulmonar, que desencadenan una respuesta mediada por leucocitos polimorfonucleares, con aumento secundario de permeabilidad del endotelio alveolocapilar.Revisamos aspectos de la fisiopatología, tratamiento y prevención. Se requiere un diagnóstico temprano del embolismo gaseoso. En algunas intervenciones neuroquirúrgicas sería útil la monitorización conjunta mediante ETCO2 y Doppler precordial (AU)

[Diagnostic and therapeutic assessment of liver trauma]. / Valoración diagnóstica y terapéutica de los traumatismos hepáticos.

We have observed an increase in the frequency of hepatic trauma. They are very severe (44% of our group in IV-V stage), right hepatic lobe is the most frequently injured (22 patients), are associated with several lesions and in 20% of patients radical proceedings (parenchymal resection) were needed. A high incidence of associated lesions (24 patients), mainly thoracic and cranio-encephalic, have been observed. Therefore we have to improve the vital support measures, both in the accident place and in their transport, as quick and safe as possible, to hospital. We have at present better diagnostic and management methods to evaluate these patients: abdominal puncture, echography and abdominal CT. The echography in emergencies is the examination of choice in severe abdominal trauma and laparatomy is an urgent procedure in uncertain cases. Most of the hepatic traumatisms were treated by conservative surgical procedures (suture, hemostasis and abdominal drainage in 25 patients), but at times hepatic resection was needed (6 patients). The main aim is this surgery is the hemorrhage control, which determines mortality and prompt reoperation. That happened in two cases. Respiratory problems, infection with sepsis, renal failure, biliary fistulas, upper digestive tract hemorrhages and hemobilia, are complications most frequently observed in our patients. The vital support measures (respiratory, cardiovascular, nutritional, neurologic, etc.) improve the clinical evolution. In our patients the mortality rate was 12%. This rate is very similar to the one reported by other authors.