Assessment of Pre-operative Measurements of Tumor Size by MRI Methods as Survival Predictors in Wild Type IDH Glioblastoma.

Objective: We evaluate the performance of three MRI methods to determine non-invasively tumor size, as overall survival (OS) and Progression Free Survival (PFS) predictors, in a cohort of wild type, IDH negative, glioblastoma patients. Investigated protocols included bidimensional (2D) diameter measurements, and three-dimensional (3D) estimations by the ellipsoid or semi-automatic segmentation methods. Methods: We investigated OS in a cohort of 44 patients diagnosed with wild type IDH glioblastoma (58.2 ± 11.4 years, 1.9/1 male/female) treated with neurosurgical resection followed by adjuvant chemo and radiotherapy. Pre-operative MRI images were evaluated to determine tumor mass area and volume, gadolinium enhancement volume, necrosis volume, and FLAIR-T2 hyper-intensity area and volume. We implemented then multivariate Cox statistical analysis to select optimal predictors for OS and PFS. Results: Median OS was 16 months (1-42 months), ranging from 9 ± 2.4 months in patients over 65 years, to 18 ± 1.6 months in younger ones. Patients with tumors carrying O6-methylguanin-DNA-methyltransferase (MGMT) methylation survived 30 ± 5.2 vs. 13 ± 2.5 months in non-methylated. Our study evidenced high and positive correlations among the results of the three methods to determine tumor size. FLAIR-T2 hyper-intensity areas (2D) and volumes (3D) were also similar as determined by the three methods. Cox proportional hazards analysis with the 2D and 3D methods indicated that OS was associated to age ≥ 65 years (HR 2.70, 2.94, and 3.16), MGMT methylation (HR 2.98, 3.07, and 2.90), and FLAIR-T2 ≥ 2,000 mm2 or ≥60 cm3 (HR 4.16, 3.93, and 3.72), respectively. Other variables including necrosis, tumor mass, necrosis/tumor ratio, and FLAIR/tumor ratio were not significantly correlated with OS. Conclusion: Our results reveal a high correlation among measurements of tumor size performed with the three methods. Pre-operative FLAIR-T2 hyperintensity area and volumes provided, independently of the measurement method, the optimal neuroimaging features predicting OS in primary glioblastoma patients, followed by age ≥ 65 years and MGMT methylation.

Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL / Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology

La parálisis de Bell es la forma más común de paresia o parálisis facial. Sin embargo, no todos los pacientes con parálisis facial tienen una parálisis de Bell. Otras causas frecuentes incluyen las secuelas del tratamiento del neurinoma del VIII par, el cáncer de cabeza y cuello, la iatrogenia, el zóster ótico y los traumatismos. El abordaje de cada una de estas situaciones es totalmente diferente. El objetivo de esta guía es servir de consejo para el tratamiento y el seguimiento de los pacientes con parálisis facial. Nuestra idea es que la guía sea práctica, haciendo hincapié en recomendaciones efectivas y útiles en el manejo diario de los pacientes. Esta guía ha sido promovida por la Sociedad Española de ORL y escrita por médicos con experiencia en la enfermedad del nervio facial, incluyendo al menos un especialista de cada comunidad autónoma. Redactada en un formato de preguntas y respuestas, incluye 56 cuestiones relevantes relacionadas con el nervio facial

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve

The Experience of a Facial Nerve Unit in the Treatment of Patients With Facial Paralysis Following Skull Base Surgery.

: The management of facial paralysis following skull base surgery is complex and requires multidisciplinary intervention. This review shows the experience of a facial nerve (FN) unit in a tertiary university referral center. A multidisciplinary approach has led to the breaking of some old treatment paradigms. An overview of five FN scenarios is presented. For each setting a contemporary approach is proposed in contrast to the established approach. 1) For patients with an anatomically preserved FN with no electrical response at the end of surgery for vestibular schwannoma, watchful waiting is usually advocated. In these cases, reinforcement with an interposed nerve graft is recommended. 2) In cases of epineural FN repair, with or without grafting, and a poor expected prognosis, an additional masseter-to-facial transfer is recommended. 3) FN transfer, mainly hypoglossal-to-facial and masseter-to facial, are usually chosen based on the surgeons' preference. The choice should be based on clinical factors. A combination of techniques improves the outcome in selected patients. 4) FN reconstruction following malignant tumors requires a combination of parotid and temporal bone surgery, involving different specialists. This collaboration is not always consistent. Exposure of the mastoid FN is recommended for lesions involving the stylomastoid foramen, as well as intraoperative FN reconstruction. 5) In patients with incomplete facial paralysis and a skull base tumor requiring additional surgery, consider an alternative reinnervation procedure, "take the FN out of the equation" before tumor resection. In summary, to achieve the best results in complex cases of facial paralysis, a multidisciplinary approach is recommended.

Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology. / Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL.

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve.

Facial nerve repair: the impact of technical variations on the final outcome.

OBJECTIVES: To analyze the outcome of facial nerve (FN) reconstruction, the impact of technical variations in different conditions and locations, and the importance of additional techniques in case of suboptimal results. STUDY DESIGN: Retrospective study. SETTING: University-based tertiary referral center. PATIENTS: Between 2001 and 2017, reconstruction of the FN was performed on 36 patients with varying underlying diseases. INTERVENTIONS: FN repair was performed by direct coaptation (n = 3) or graft interposition (n = 33). Microsurgical sutures were used in 17 patients (47%) and fibrin glue was used in all cases. Additional reinnervation techniques (hypoglossal-facial or masseter-facial transfers) were performed in five patients with poor results after initial reconstruction. MAIN OUTCOME MEASURES: FN function was evaluated using the House-Brackmann (HB) and the electronic clinician-graded facial function (eFACE) grading systems. Minimum follow-up was 12 months. RESULTS: FN reconstruction yielded improvement in 83% of patients, 21 patients (58.3%) achieving a HB grade III. The eFACE median composite, static, dynamic and synkinesis scores were 69.1, 78, 53.2, and 88.2 respectively. A tendency towards better outcome with the use of sutures was found, the difference not being significant. All patients undergoing an additional reinnervation procedure achieved a HB grade III, eFACE score being 74.8. CONCLUSIONS: FN reconstruction offers acceptable functional results in most cases. No significant differences are expected with technical variations, different locations or conditions. In patients with poor initial results, additional reinnervation techniques should be always considered. The eFACE adds substantial information to the most used HB scale.

Early toll-like receptor 4 blockade reduces ROS and inflammation triggered by microglial pro-inflammatory phenotype in rodent and human brain ischaemia models.

BACKGROUND AND PURPOSE: Ischaemic stroke is a leading cause of death, disability, and a high unmet medical need. Post-reperfusion inflammation and an up-regulation of toll-like receptor 4 (TLR4), an upstream sensor of innate immunity, are associated with poor outcome in stroke patients. Here, we identified the therapeutic effect of targeting the LPS/TLR4 signal transduction pathway. EXPERIMENTAL APPROACH: We tested the effect of the TLR4 inhibitor, eritoran (E5564) in different in vitro ischaemia-related models: human organotypic cortex culture, rat organotypic hippocampal cultures, and primary mixed glia cultures. We explored the therapeutic window of E5564 in the transient middle cerebral artery occlusion model of cerebral ischaemia in mice. KEY RESULTS: In vivo, administration of E5564 1 and 4 hr post-ischaemia reduced the expression of different pro-inflammatory chemokines and cytokines, infarct volume, blood-brain barrier breakdown, and improved neuromotor function, an important clinically relevant outcome. In the human organotypic cortex culture, E5564 reduced the activation of microglia and ROS production evoked by LPS. CONCLUSION AND IMPLICATIONS: TLR4 signalling has a causal role in the inflammation associated with a poor post-stroke outcome. Importantly, its inhibition by eritoran (E5564) provides neuroprotection both in vitro and in vivo, including in human tissue, suggesting a promising new therapeutic approach for ischaemic stroke.

Assessment of Overall Survival in Glioma Patients as Predicted by Metabolomic Criteria.

Objective: We assess the efficacy of the metabolomic profile from glioma biopsies in providing estimates of postsurgical Overall Survival in glioma patients. Methods: Tumor biopsies from 46 patients bearing gliomas, obtained neurosurgically in the period 1992-1998, were analyzed by high resolution 1H magnetic resonance spectroscopy (HR- 1H MRS), following retrospectively individual postsurgical Overall Survival up to 720 weeks. Results: The Overall Survival profile could be resolved in three groups; Short (shorter than 52 weeks, n = 19), Intermediate (between 53 and 364 weeks, n = 19) or Long (longer than 365 weeks, n = 8), respectively. Classical histopathological analysis assigned WHO grades II-IV to every biopsy but notably, some patients with low grade glioma depicted unexpectedly Short Overall Survival, while some patients with high grade glioma, presented unpredictably Long Overall Survival. To explore the reasons underlying these different responses, we analyzed HR-1H MRS spectra from acid extracts of the same biopsies, to characterize the metabolite patterns associated to OS predictions. Poor prognosis was found in biopsies with higher contents of alanine, acetate, glutamate, total choline, phosphorylcholine, and glycine, while more favorable prognosis was achieved in biopsies with larger contents of total creatine, glycerol-phosphorylcholine, and myo-inositol. We then implemented a multivariate analysis to identify hierarchically the influence of metabolomic biomarkers on OS predictions, using a Classification Regression Tree (CRT) approach. The CRT based in metabolomic biomarkers grew up to three branches and split into eight nodes, predicting correctly the outcome of 94.7% of the patients in the Short Overall Survival group, 78.9% of the patients in the Intermediate Overall Survival group, and 75% of the patients in the Long Overall Survival group, respectively. Conclusion: Present results indicate that metabolic profiling by HR-1H MRS improves the Overall Survival predictions derived exclusively from classical histopathological gradings, thus favoring more precise therapeutic decisions.

Protocolo para la valoración anatomopatológica de las piezas de cirugía de carcinomatosis peritoneal de origen ovárico, tubárico y peritoneal / Protocol for the examination of surgical specimens from patients with peritoneal carcinomatosis originating in ovary, fallopian tube and peritoneum

La carcinomatosis peritoneal (CP) es una entidad tumoral con una alta tasa de morbimortalidad, considerada la evolución común de varias neoplasias abdominopélvicas, entre ellas, el carcinoma de ovario, trompa uterina y peritoneo. Aunque muchos de estos tumores son sensibles a quimioterapia sistémica, el pronóstico es desfavorable por la elevada tasa de recurrencia. La cirugía de citorreducción (CC) se emplea como tratamiento de primera línea en los estadios avanzados, ya que aumenta la supervivencia de los pacientes cuando la CC es óptima. El procedimiento terapéutico descrito por Sugarbaker para el carcinoma de colon en la década de los 80, que incluye CC y quimioterapia intraperitoneal ha sido adaptado a la CP de origen ginecológico. El estudio anatomopatológico de esta cirugía empieza a ser una práctica habitual en algunos de nuestros servicios. Es un procedimiento complejo, que requiere especialización y sistematización para valorar un gran número de piezas quirúrgicas, cuantificando de forma lo más objetiva posible la carga tumoral. El objetivo de este trabajo es mostrar la experiencia inicial en nuestro servicio de anatomía patológica con pacientes diagnosticadas de CP de origen ovárico, tubárico y peritoneal y sometidas a cirugía citorreductora, destacando el papel del patólogo. Mostramos el esquema de trabajo utilizado en nuestro servicio y resumimos los resultados iniciales de 31 pacientes intervenidas entre enero de 2013 y julio de 2014

Peritoneal carcinomatosis (PC) is a malignant entity with a high rate of morbimortality. It is considered an end-stage common to several abdominal and pelvic malignant tumours, such as epithelial ovarian, fallopian tubal and peritoneal cancer. Although many of these tumors have a good response to chemotherapy, prognosis is poor due to the high rate of recurrence. Surgeons, gynecologists and oncologists are increasingly concerned with improving the survival. The surgical technique described by Sugarbaker in the eighties is a plausible option. It aims for a complete resection of macroscopic carcinomatosis (cytoreductive surgery) followed by intraoperative or perioperative intraperitoneal chemotherapy. This therapeutic option necessarily involves specific multidisciplinary units; histopathology of specimens from this surgical technique is now more frequent in our department. We describe our initial experience with PC originating from epithelial ovarian, tubal and peritoneal cancer treated with the modified Sugarbaker surgery employed in our hospital. We outline our protocol designed to achieve uniformity in procedure, and summarize the initial results

[Protocol for the examination of surgical specimens from patients with peritoneal carcinomatosis originating in ovary, fallopian tube and peritoneum]. / Protocolo para la valoración anatomopatológica de las piezas de cirugía de carcinomatosis peritoneal de origen ovárico, tubárico y peritoneal.

Peritoneal carcinomatosis (PC) is a malignant entity with a high rate of morbimortality. It is considered an end-stage common to several abdominal and pelvic malignant tumours, such as epithelial ovarian, fallopian tubal and peritoneal cancer. Although many of these tumors have a good response to chemotherapy, prognosis is poor due to the high rate of recurrence. Surgeons, gynecologists and oncologists are increasingly concerned with improving the survival. The surgical technique described by Sugarbaker in the eighties is a plausible option. It aims for a complete resection of macroscopic carcinomatosis (cytoreductive surgery) followed by intraoperative or perioperative intraperitoneal chemotherapy. This therapeutic option necessarily involves specific multidisciplinary units; histopathology of specimens from this surgical technique is now more frequent in our department. We describe our initial experience with PC originating from epithelial ovarian, tubal and peritoneal cancer treated with the modified Sugarbaker surgery employed in our hospital. We outline our protocol designed to achieve uniformity in procedure, and summarize the initial results.

Réplica a la carta al director del Dr Moreno Mira, R / No disponible

No disponible

Técnica quirúrgica de la linfadenectomía inguinal vídeo endoscópica en el cáncer de vulva / Surgical technique for video endoscopic inguinal lymphadenectomy in vulvar cancer

Introducción: la afectación de los nódulos linfáticos inguinales es un factor pronóstico importante en pacientes con cáncer de vulva. La disección de los nódulos linfáticos inguinales nos permite la estadificación y el tratamiento de la afectación ganglionar inguinal. Por otra parte, causa morbilidad y está asociada a complicaciones como linfocele, dehiscencia de la herida e infección. La linfadenectomía inguinal vídeo endoscópica parece ser una nueva y atractiva técnica con menor morbilidad que el abordaje abierto. El objetivo de este trabajo es reportar nuestra técnica de linfadenectomía inguinal vídeo endoscópica para el tratamiento del cáncer de vulva. Métodos: se evaluó de manera retrospectiva el caso de una paciente de 78 años de edad con cáncer de vulva a la que se realizó una linfadenectomía inguinal vídeo endoscópica bilateral. Hallazgos: el tiempo operatorio fue de 140 min y no hubieron complicaciones. Tras 3 meses de seguimiento no se observaron signos de edema vulvar, linfedema o linfocele. Conclusiones: la linfadenectomía inguinal vídeo endoscópica en pacientes con cáncer de vulva es factible en la práctica clínica. Estudios adicionales con un mayor número de pacientes y a más largo plazo de seguimiento son necesarios para confirmar la eficacia oncológica y la posible menor morbilidad de este nuevo enfoque (AU)

Inguinal lymph node dissection allows for staging and treatment of inguinal node disease but causes morbidity and is associated with complications such as lymphocele formation, wound dehiscence, and infection. Video endoscopic inguinal lymphadenectomy (VEIL) seems to be a new and attractive approach with lower morbidity than the standard open procedure. The objective of this study was to report our surgical technique for VEIL for the treatment of vulvar cancer. Methods: We retrospectively evaluated a case involving a 78-year-old woman with vulvar cancer who underwent bilateral VEIL. Findings: The operative time was 140 min, and there were no complications. After 3 months of follow-up, there were no signs of vulvar oedema, lymphedema, or lymphocele. Conclusions: In patients with vulvar cancer, VEIL is feasible in clinical practice. Additional studies with a larger number of patients and longer-term follow-up are needed to confirm the oncological efficacy and the possible reduction in morbidity of this new approach (AU)

Evolution of Patients With Immediate Complete Facial Paralysis Secondary to Acoustic Neuroma Surgery.

OBJECTIVE: To study the evolution of patients with immediate complete facial paralysis after acoustic neuroma surgery in different scenarios and assess different facial reanimations techniques. METHODS: This study included 50 patients with complete facial paralysis immediately after acoustic neuroma surgery. Data were analyzed into 4 groups according to the need and type of reconstruction of the facial nerve, either none, immediate, or on a deferred basis. All patients had intraoperative facial nerve monitoring, and facial nerve function was evaluated according the House-Brackmann (HB) scale. RESULTS: Of all patients with immediate total paralysis, no patients achieved totally normal facial function (grade I), and only 5 (10%) recovered to a grade II. For all groups included, the majority of patients (82%) achieved an acceptable final facial function (grade III HB). In this series, only 2 patients remained with a grade VI facial function. CONCLUSIONS: The possibility of recovering near normal facial function after a grade VI facial paralysis is very low. Procedures like the immediate repair of the facial nerve with an interposed donor graft may provide better facial function in patients with partially injured facial nerve. Even in cases of total section, there are other procedures that can improve the results.

Evaluación y soporte nutricional en pacientes con carcinomatosis peritoneal por cáncer de ovario con citorreducción quirúrgica / Nutritional assessment and support in patients with peritoneal carcinomatosis of ovarian cancer with cytoreductive surgery

Introducción: El tratamiento multidisciplinar de la carcinomatosis peritoneal, también conocido como procedimiento Sugarbaker, pretende erradicar el tumor microscópico residual a la cirugía. Esta técnica de alta complejidad está asociada a morbilidad y mortalidad elevada por lo que es relevante la selección de los pacientes. Existe una relación directa entre el estado nutricional, la calidad de vida, la supervivencia y la capacidad de tolerancia al tratamiento. Por tanto, es importante evaluar previamente el estado nutricional para detectar si existe riesgo de malnutrición. Objetivos: El objetivo principal es evaluar los resultados de la valoración nutricional completa previa a to das las pacientes intervenidas por el procedimiento Sugarbaker. Los objetivos secundarios son: conocer las composición promedio de la fórmula de nutrición parenteral más utilizada y comparar los resultados obtenidos de dichas pacientes con una cohorte histórica a la que no se realizó la valoración nutricional previa. Métodos: Estudio prospectivo donde se incluyeron todas las pacientes adultas que se iban a someter al procedimiento Sugarbaker a las que se les realizó la valoración nutricional previa. Se compararon los datos clínicos del seguimiento postoperatorio de las pacientes con una cohorte histórica retrospectiva de pa cientes sometidas al mismo procedimiento (a las que no se les realizó la valoración nutricional previa). Los parámetros que se utilizaron para el diagnóstico de malnutrición fueron antropométricos y analíticos. Los parámetros de estudio fueron los siguientes: edad, albúmina previa a la intervención, índice de carcinomatosis peritoneal, la administración o no de quimioterapia previa a la intervención y el estadiaje del tumor. En el seguimiento postoperatorio se establecieron como parámetros a valorar: días en unidad de cuidados intensivos, días en planta, días totales de hospitalización y complicaciones postoperatorias. Resultados: Se incluyeron un total de 32 pacientes: veinte pacientes sin valoración nutricional previa y doce pacientes con valoración nutricional previa con una edad media de 58,9±14 años. No se observan diferencias estadísticamente significativas entre ambos grupos en índice de carcinomatosis peritoneal, estadio tumoral, quimioterapia previa a la intervención y albúmina previa a la intervención. Requirieron nutrición parenteral 30 pacientes durante el postoperatorio. La composición media de la fórmula de nutrición parenteral fue 1,2±0,1 g de proteína por kg peso y día, 2,8±0,4g de hidratos de carbono por kg peso y día y 1±0,1g de lípidos por kg peso y día. De las doce valoraciones nutricionales previas realizadas, en nueve de ellas se observó algún tipo de desnutrición. En los parámetros evaluados durante el seguimiento de las pacientes no se obtuvieron diferencias estadísticamente significativas, aunque se observó una tendencia a una menor estancia en la unidad de cuidados intensivos y un menor número de complicaciones en las pacientes a las que se les ha realizado valoración nutricional previa. Discusión: Se observa que el índice de masa corporal y el porcentaje de pérdida de peso en estas pacientes no es representativo de la desnutrición que presentan. Las necesidades elevadas de nutrición parenteral en este estudio pueden ser debidas las complicaciones derivadas de la resección gastrointestinal. Posiblemente no se observen diferencias en los parámetros de estudio debido al tamaño muestral del mismo, pero si existe una tendencia a disminuir la estancia y complicaciones como muestra la bibliografía. La intervención nutricional aporta la energía y proteínas necesarias para disminuir la pérdida de peso y de masa muscular derivada del proceso patológico del cáncer y la cirugía. Conclusiones: Los resultados de la valoración nutricional previa indican que la desnutrición es una patología que tiene elevada prevalencia en las pacientes con carcinomatosis peritoneal de origen ovárico. Se observa una tendencia de que la mejora del estado nutricional aumentará la calidad de vida reduciendo estos parámetros. La composición en macronutrientes de la nutrición parenteral es similar a los requierimientos nutricionales en un paciente crítico. Consideramos que la selección de pacientes que van a ser sometidos a un procedimiento Sugarbaker debe incluir la evaluación del estado nutricional previo

Introduction: The multidisciplinary treatment of peritoneal carcinomatosis, also known as Sugarbaker´s procedure, aims to eradicate microscopic residual tumor after surgery. This technique is highly complex and it´s associated with high mortality and morbidity, so the patient selection is relevant. There is a direct relationship between nutritional status, quality of life, survival and ability to tolerate treatment. It is therefore important to assess nutritional status prior to detect if there is risk or malnutrition. Objectives: The main objective is to evaluate the results of the nutritional assessment after all patients operated by Sugarbaker´s procedure. Secondary objectives are to know the parenteral nutrition composition formula most commonly used and to compare the results of those patients with a historical cohort to which the previous nutritional assessment wasn´t performed.. Methods: Prospective study where all adult patients who were undergoing Sugarbaker procedure and who underwent previous nutritional assessment were included. Postoperative clinical and patient follow-up data were compared with a historical cohort of patients undergoing the same procedure (which will not be made prior nutritional assessment). For the diagnosis of malnutrition were used anthropometric and laboratory parameters. Study parameters were: age, albumin prior to the intervention, peritoneal carcinomatosis index, quimiotherapy administration and tumor staging. In the postoperative follow-up, the study parameters were: days in intensive care unit, hospitalization days, total days of hospitalization and postoperative complications. Results: A total of 32 patients were included: twenty patients without nutritional assessment and twelve patients with previous nutritional assessment with a mean age of 59 ± 14 years. No statistically significant differences are observed between groups in peritoneal carcinomatosis index, tumor stage, chemotherapy and albumin before the intervention. A total of 30 patients were required parenteral nutrition. The average composition formula of parenteral nutrition was 1.2 ± 0.1 g proteins per kg body weight and per day, 2.8 ± 0.4 g of carbohydrates per kg body weight and per day and 1 ± 0.1 g of lipid per kg body weight and per day. Of the twelve previous nutritional assessment conducted in nine of them some form of malnutrition was observed. In the parameters evaluated during follow-up of patients, no statistically significant differences were found, although was observed a trend to a shorter in the intensive care unit stay and fewer complications in patients who have undergone nutritional assessment. Discussion: It should be noted that body mass index and the percentage weight loss in these patients is not representative of the observed malnutrition. The high needs of parenteral nutrition in this study may be due the complications of gastrointestinal resection. Possibly no differences are observed in study parameters due to sample size, but if there is a tendency to increase the stay and complications as shown in the literature. Nutritional intervention provides energy and protein needed to reduce the loss of weight and muscle mass from the pathological process of cancer and surgery. Conclusions: The results of the previous nutritional assessment indicate that malnutrition is a pathology that has high prevalence in patients with peritoneal carcinomatosis of ovarian origin. A trend that improve nutritional status will increase the quality of life by reducing these parameters is observed. The macronutrient composition of parenteral nutrition is similar to nutritional requirement in critically ill patients. We believe that the selection of patients who are going to undergo a Sugarbaker procedure should include assessment of prior nutritional status

Current status of ovarian cancer in the Spanish Province of Castellon. Prognostic factors in observed and relative survival. A population cancer-registry-based study between 2004 and 2008 / Estado actual del cáncer de ovario en la provincia de Castellón. Factores pronósticos en la supervivencia observada y relativa. Un estudio basado en registros poblacionales de cáncer de entre 2004 y 2008

Background. The aim of this population-based study was to assess independent prognostic factors in ovarian cancer by analyzing observed and relative survival in a representative Spanish population. Methods. We carried out a retrospective, observational, population-registry-based study. Data on 207 patients with ovarian cancer were provided by the Castellon Cancer Registry. Observed and relative survival were described at 1, 3 and 5 years. The effect of prognostic factors on survival was assessed with univariate and multivariate analyses. Results. The median follow-up was 40.8 months (range: 12-108 months). Observed and relative survival rates at 1, 3 and 5 years were 79%, 51%, 33%, and 84%, 58%, 40%, respectively. Age older than 70 years showed worse observed survival in the univariate and multivariate analyses. Only FIGO stage was an independent prognostic factor for observed and relative survival. Conclusions. Survival is poor in patients with ovarian cancer. In our population-registry-based study, only age at diagnosis and FIGO stage were independent prognostic factors for observed survival, whereas only FIGO stage could be considered a prognostic factor for relative survival (AU)

Antecedentes. El objetivo de este estudio poblacional fue evaluar los factores pronósticos independientes de cáncer de ovario mediante el análisis de la supervivencia observada y relativa en una población española representativa. Métodos. Se realizó un estudio retrospectivo, observacional, y basado en un registro de población. Los datos de 207 pacientes con cáncer de ovario proceden del Registro de Cáncer de Castellón. Se describió la supervivencia observada y relativa a 1, 3 y 5 años. El efecto de los factores pronósticos en la supervivencia se evaluó mediante análisis univariantes y multivariantes. Resultados. La mediana de seguimiento fue de 40,8 meses (intervalo: 12-108 meses). Las tasas de supervivencia observada y relativa a 1, 3 y 5 años fueron de 79%, 51% y 33% y de 84%, 58% y 40%, respectivamente. La edad superior a los 70 años mostró la peor supervivencia observada en los análisis univariantes y multivariantes. Sólo el estadio en la clasificación FIGO fue un factor pronóstico independiente de la supervivencia observada y relativa. Conclusiones. La supervivencia en los pacientes con cáncer de ovario es limitada. En nuestro estudio basado en un registro de población, sólo la edad en el momento del diagnóstico y el estadio de FIGO fueron factores pronósticos independientes para la supervivencia observada, mientras que sólo el estadio de la FIGO se podría considerar un factor pronóstico en la supervivencia relativa (AU)

Guía de actuación clínica en la hemorragia subaracnoidea. Sistemática diagnóstica y tratamiento / Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment

OBJETIVO: Actualización de la guía para el diagnóstico y tratamiento de la hemorragia subaracnoidea de la Sociedad Española de Neurología. MATERIAL Y MÉTODOS: Revisión y análisis de la bibliografía existente. Se establecen recomendaciones en función del nivel de evidencia que ofrecen los estudios revisados. RESULTADOS: La causa más frecuente de hemorragia subaracnoidea espontánea (HSA) es la rotura de un aneurisma cerebral. Su incidencia se sitúa en torno 9 casos por 100.000 habitantes/año y supone un 5% de todos los ictus. La hipertensión arterial y el tabaquismo son sus principales factores de riesgo. Se ha de realizar el tratamiento en centros especializados. Se debe considerar el ingreso en unidades de ictus de aquellos pacientes con HSA y buena situación clínica inicial (grados I y II en la escala de Hunt y Hess). Se recomienda la exclusión precoz de la circulación del aneurisma. El estudio diagnóstico de elección es la tomografía computarizada (TC) craneal sin contraste. Si esta es negativa y persiste la sospecha clínica se aconseja realizar una punción lumbar. Los estudios de elección para identificar la fuente de sangrado son la resonancia magnética (RM) y la angiografía. Los estudios ultrasonográficos son útiles para el diagnóstico y seguimiento del vasoespasmo. Se recomienda el nimodipino para la prevención de la isquemia cerebral diferida. La terapia hipertensiva y el intervencionismo neurovascular pueden plantearse para tratar el vasoespasmo establecido. CONCLUSIONES: La HSA es una enfermedad grave y compleja que debe ser atendida en centros especializados, con suficiente experiencia para abordar el proceso diagnóstico y terapéutico

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes

End-to-Side interposed donor grafting as a facial nerve reinforcement technique after vestibular schwannoma surgery.

OBJECTIVES: This retrospective case review was performed to determine the facial function outcome of an end-to-side interposed donor grafting technique in patients who had a nonresponsive and partially injured facial nerve during a translabyrinthine approach for vestibular schwannoma resection. METHODS: The study included patients with silent electrophysiological tests after partial injury of the facial nerve during translabyrinthine schwannoma resection surgery in a tertiary referral hospital. The patients underwent end-to-side interposed donor grafting as a facial nerve reinforcement technique, and we evaluated their facial function after 1 year of follow-up. RESULTS: Four cases with intact preoperative facial function were included (3 men and 1 woman). All patients had a lack of electrical response from the facial nerve and partial anatomic injury after a translabyrinthine approach. An end-to-side interposed donor grafting technique was performed. The donor grafts used were the sural nerve (2 patients), superior vestibular nerve (1 patient), and greater auricular nerve (1 patient). All patients achieved a good House-Brackmann grade. Ocular adjuvant procedures were performed in all patients. CONCLUSIONS: Immediate repair of the facial nerve with an interposed donor graft may provide better facial function in patients who have no electrical response from a partially injured facial nerve after vestibular schwannoma surgery.

NF2 genetic alterations in sporadic vestibular schwannomas: clinical implications.

HYPOTHESIS: NF2 gene alterations may have a clinical impact in non-NF2 vestibular schwannomas (VSs). BACKGROUND: It has been suggested that NF2 mutations might correlate with clinical expression of VS in NF2 patients. The aim of this study was to analyze the impact of genetic alterations in the NF2 gene on epidemiologic, clinical, and radiologic features of patients with sporadic VS. The association between cigarette consumption and the molecular genetic findings was also studied. METHODS: The study group consisted of 51 patients who underwent surgery for removal of vestibular schwannoma in our institution between January 2006 and December 2010. Five highly polymorphic microsatellite DNA markers were used to observe the frequency of loss of heterozygosity (LOH) in chromosome 22. The NF2 gene mutations were detected using polymerase chain reaction amplification and denaturing high-performance liquid chromatography analysis (PCR/dHPLC), and direct sequencing of NF2. Multiplex ligation-dependent probe amplification (MLPA) of the NF2 gene was also performed. RESULTS: An NF2 mutation was identified in 49%, 22q LOH in 57%, and MLPA alterations in 13.7% of the cases. One mutational hit was present in 27%, and 2 hits were present in 45% of the tumors. No association was found between the type of NF2 mutation and relevant clinical parameters. The presence of NF2 mutations detected by PCR/dHPLC was associated with no complaint of hearing loss at the time of diagnosis (p = 0.023), with subjective aural fullness (p = 0.022) and with an absence of tumor involvement of the internal auditory canal (p = 0.029). Patients with NF2 mutations had lower mean corrected PTA thresholds compared with those with no NF2 mutation (p = 0.037). Inactivation of the NF2 gene by mutation, MLPA, or LOH was more frequent in smokers when compared with never smokers (p = 0.048). CONCLUSION: NF2 mutations may play a role in the pathophysiology of hearing loss as well as in the pattern of growth of VS. Cigarette smoking in patients with VS seems to play a role in both the risk of developing the tumor and also in its genetic profile. More studies are needed to corroborate these results and, more broadly, to establish links between molecular and clinical data.

Novel multitarget ligand ITH33/IQM9.21 provides neuroprotection in in vitro and in vivo models related to brain ischemia.

ITH33/IQM9.21 is a novel compound belonging to a family of glutamic acid derivatives, synthesized under the hypothesis implying that multitarget ligands may provide more efficient neuroprotection than single-targeted compounds. In rat hippocampal slices, oxygen plus glucose deprivation followed by re-oxygenation (OGD/Reox) elicited 42% cell death. At 1 µM, ITH33/IQM9.21 mitigated this damage by 26% and by 55% at 3 µM. OGD/Reox also elicited mitochondrial depolarization, overproduction of reactive oxygen species (ROS), enhanced expression of nitric oxide synthase (iNOS) and reduction of GSH levels. These changes were almost fully prevented when 3 µM ITH33/IQM9.21 was present during slice treatment with OGD/Reox. In isolated hippocampal neurons, ITH33/IQM9.21 reduced [Ca(2+)](c) transients induced by a high K(+) depolarizing solution or glutamate. In a photothrombotic model of stroke in mice, intraperitoneal injection of ITH33/IQM9.21 at 1.25 mg/kg, 2.5 mg/kg or 5 mg/kg given before and during 2 days after stroke induction, reduced infarct volume by over 45%. Furthermore, when the compound was administered 1 h post-stroke, a similar effect was observed. In conclusion, these in vitro and in vivo results suggest that ITH33/IQM9.21 exhibits neuroprotective effects to protect the vulnerable neurons at the ischemic penumbra by an effective and multifaceted mechanism, mediated by reduction of Ca(2+) overload, providing mitochondrial protection and antioxidant actions.

CDP-choline at high doses is as effective as i.v. thrombolysis in experimental animal stroke.

Use of thrombolysis in acute ischaemic stroke may be limited by a narrow benefit/risk ratio. Pharmacological inhibition of the ischaemic cascade may constitute an effective and safer approach to stroke treatment. This study compared the effects of high doses of cytidine diphosphate-choline (CDP-choline; 1000 mg/kg) with recombinant tissue plasminogen activator (rt-PA; 5 mg/kg) in an experimental animal model of embolic stroke. Fifteen rats were embolized in the right internal carotid artery with an autologous clot and were divided into three groups: (1) infarct; (2) intravenous rt-PA 5 mg/kg 30 minutes post-embolization; and (3) CDP-choline 1000 mg/kg, intraperitoneal, three doses, 30 minutes, 24 hours, and 48 hours post-embolization. Functional evaluation scores were evaluated using Rogers test, lesion volume by haematoxylin and eosin staining, cell death with transferase-mediated dUTP nick-end labelling, and plasma levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha with enzyme-linked immunosorbent assay. In this study, CDP-choline and rt-PA produced a significant reduction in brain damage considering infarct volume, cell death, and inflammatory cytokines (tumour necrosis factor-alpha and IL-6) compared with the infarct group. Additionally, CDP-choline significantly decreased infarct volume, cell death, and IL-6 levels with respect to the rt-PA group. From these results, we conclude that high-dose CDP-choline may be an effective treatment for acute ischaemic stroke even in absence of thrombolysis.