Resumen ejecutivo del documento de consenso sobre el manejo de la anemia perioperatoria en España / Executive summary of the consensus document on the management of perioperative anemia in Spain

La anemia perioperatoria constituye un factor independiente de riesgo de morbimortalidad posoperatoria. Sin embargo, persisten barreras conceptuales, logísticas y administrativas que dificultan la implementación generalizada de protocolos para su manejo. El coordinador del proyecto convocó a un grupo multidisciplinar de ocho profesionales para elaborar un documento de consenso sobre el manejo de la anemia perioperatoria, con base a en serie puntos claves (PCs) relativos a su prevalencia, consecuencias, diagnóstico y tratamiento. Estos PCs fueron evaluados utilizando una escala Likert de 5 puntos, desde «totalmente en desacuerdo [1]» a «totalmente de acuerdo [5]». Cada PC se consideró consensuado si recibía una puntuación de 4 o 5 por al menos siete participantes (> 75%). A partir de los 36 PCs consensuados, se construyeron algoritmos diagnóstico-terapéuticos que pueden facilitar la implementación de programas de identificación precoz y manejo adecuado de la anemia perioperatoria, adaptados a las características de las instituciones hospitalarias de nuestro país.(AU)

Perioperative anemia is an independent risk factor for postoperative morbidity and mortality. However, conceptual, logistical and administrative barriers persist that hinder the widespread implementation of protocols for their management. The project coordinator convened a multidisciplinary group of 9 experienced professionals to develop perioperative anemia management algorithms, based on a series of key points (KPs) related to its prevalence, consequences, diagnosis and treatment. These KPs were assessed using a 5-point Likert scale, from “strongly disagree [1]” to “strongly agree [5]”. For each KP, consensus was reached when receiving a score of 4 or 5 from at least 7 participants (>75%). Based on the 36 KPs agreed upon, diagnostic-therapeutic algorithms were developed that we believe can facilitate the implementation of programs for early identification and adequate management of perioperative anemia, adapted to the characteristics of the different institutions in our country.(AU)

Executive summary of the consensus document on the management of perioperative anemia in Spain.

Perioperative anemia is an independent risk factor for postoperative morbidity and mortality. However, conceptual, logistical and administrative barriers persist that hinder the widespread implementation of protocols for their management. The project coordinator convened a multidisciplinary group of 8 experienced professionals to develop perioperative anemia management algorithms, based on a series of key points (KPs) related to its prevalence, consequences, diagnosis and treatment. These KPs were assessed using a 5-point Likert scale, from "strongly disagree [1]" to "strongly agree [5]". For each KP, consensus was reached when receiving a score of 4 or 5 from at least 7 participants (>75%). Based on the 36 KPs agreed upon, diagnostic-therapeutic algorithms were developed that we believe can facilitate the implementation of programs for early identification and adequate management of perioperative anemia, adapted to the characteristics of the different institutions in our country.

Social mobility and healthy behaviours from a gender perspective in the Spanish multicase-control study (MCC-Spain).

There is evidence for the influence of socioeconomic status (SES) on healthy behaviours but the effect of social mobility (SM) is not yet well known. This study aims to analyse the influence of origin and destination SES (O-SES and D-SES) and SM on healthy behaviours and co-occurrence, from an integrated gender and age perspective. Data were obtained from the controls of MCC-Spain between 2008-2013 (3,606 participants). Healthy behaviours considered: healthy diet, moderate alcohol consumption, non-smoking and physical activity. SM was categorized as stable high, upward, stable medium, downward or stable low. Binary and multinomial logistic regression models were adjusted. Those aged <65, with a low O-SES, D-SES and stable low SM are less likely to have healthy behaviours in the case of both women (physically active: OR = 0.65 CI = 0.45-0.94, OR = 0.71 CI = 0.52-0.98, OR = 0.61 CI = 0.41-0.91) and men (non-smokers: OR = 0.44 CI = 0.26-0.76, OR = 0.54 CI = 0.35-0.83, OR = 0.41 CI 0.24-0.72; physically active: OR = 0.57 CI = 0.35-0.92, OR = 0.64 CI = 0.44-0.95, OR = 0.53 CI = 0.23-0.87). However, for those aged ≥65, this probability is higher in women with a low O-SES and D-SES (non-smoker: OR = 8.09 CI = 4.18-15.67, OR = 4.14 CI = 2.28-7.52; moderate alcohol consumption: OR = 3.00 CI = 1.45-6.24, OR = 2.83 CI = 1.49-5.37) and in men with a stable low SM (physically active: OR = 1.52 CI = 1.02-1.26). In the case of men, the same behaviour pattern is observed in those with a low O-SES as those with upward mobility, with a higher probability of co-occurring behaviours (three-to-four behaviours: OR = 2.00 CI = 1.22-3.29; OR = 3.13 CI = 1.31-7.48). The relationship of O-SES, D-SES and SM with healthy behaviours is complex and differs according to age and gender.

Efectividad del doble test bioquímico como prueba de cribado de síndrome de Down en el segundo trimestre / Effectiveness of the double test in screening for Down syndrome in the second trimester of pregnancy

Para determinar la población de riesgo de síndrome de Down a la que debe recomendarse realizar una te ́cnica invasiva para obtener un cariotipo fetal existen varias pruebas de cribado. En nuestro centro se realiza con el cribado del primer trimestre (edad materna + - translucencia nucal +b-HCG + PAPP-A). Cuando éste no es posible, se realiza el doble test (AFP+b- HCG) como cribado de segundo trimestre. Los resultados del doble test en nuestro centro son insatisfactorios ya que tenemos una tasa de detección del 0%, con una tasa de falsos positivos del 7,7%. Por ello consideramos que es necesaria la utilización de otros criterios alternativos para la selección de las mujeres de riesgo de síndrome de Down en el segundo trimestre (AU)

Several screening tests are available to identify the population at risk of Down syndrome. This population should then be recommended to undergo an invasive technique to obtain a fetal karyotype. In our hospital, screening is done by the combined test (maternal age + nuchal translucency + b subunit of human chorionic gonadotropin [b-HCG] + pregnancy- associated plasma-A [PAPP-A]) during the first trimester of pregnancy. When this test is not feasible, we request the double test (alpha-fetoprotein [AFP] + b-HCG) as a second trimester screening test. The results of the double test in our hospital were unsatisfactory because the detection rate was 0% with a false positive rate of 7.7%. Therefore, we believe alternative criteria should be used to select women at risk of having a child with Down syndrome in the second trimester (AU)

Actitud ante el diagnóstico ecográfico de un hydrops fetal / Management in ultrasound diagnosis of fetal hydrops

El diagnóstico del hydrops fetal obedece generalmente a un hallazgo ecográfico casual. El manejo terapéutico varía en función de la etiología del proceso, por lo que resulta básico filiar su origen. Presentamos un caso de hydrops fetal diagnosticado en el segundo trimestre de gestación; el cariotipo reveló un síndrome de Turner, y el resto de las pruebas solicitadas fueron normales

Diagnosis of hydrops fetalis usually follows an incidental finding on an ultrasound scan. The therapeutic management varies according to the etiology of the process and therefore it is essential to determine its origin. We report a case of hydrops fetalis diagnosed in the second trimester of gestation. The karyotype revealed Turner's syndrome, while the results of remaining tests were normal

Masa auricular izquierda / Left auricular mass

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Presentación de un linfoma testicular como escroto agudo. Actitud diagnóstica y valoración del eco-doppler / Testicular lymphoma presenting as acute scrotum. Diagnostic approach as doppler-ultrasound assessment

Presentamos un linfoma testicular en un paciente que acude a urgencias con un cuadro similar al de un escroto agudo, al que se le realiza una ecografía convencional y doppler. Los hallazgos sugieren un tumor, probablemente linfoma dada la edad del paciente y la imagen radiológica. No obstante, es la falta de respuesta al tratamiento antibiótico lo que indica la orquiectomia biópsica. Destacamos la similitud entre la orquitis y el linfoma testicular, el tumor mas frecuente en varones mayores de 50 años. El diagnóstico por ecografía es sugestivo, pero no definitivo; suelen ser masas hipoecogénicas e hipervasculares si son mayores de 15 mm. La no afectación de epidídimo sugiere con mayor fuerza la naturaleza tumoral. El tratamiento debe ser quirúrgico y quimioterapia. El pronostico es malo con una supervivencia a los 5 años entre el 5-20 por ciento (AU)

Monitorización antenatal rutinaria en gestantes de bajo riesgo obstétrico / Routine monitoring of low obstetric risk gestants

Nuestro objetivo fue evaluar el beneficio y el momento de inicio del test no estresante en los embarazos de bajo riesgo obstétrico de nuestro medio. Estudio retrospectivo de 100 gestaciones sin enfermedad asociada procedentes de nuestras consultas externas. Se evaluaron los siguientes parámetros: edad materna, paridad, test no estresante (TNS) semanal desde la semana 38 hasta el momento del parto, recuento de movimientos fetales, prueba de Pose cuando fue necesaria, monitorización intraparto, estudio bioquímico fetal cuando fue preciso, tipo de parto, peso del recién nacido (RN) y test de Apgar al primer y quinto minutos. Se realizó un estudio descriptivo de todas las variables y se compararon los resultados del último TNS con el test de Apgar del RN. Se consideraron significativos los valores de p < 0,05. Sólo se registró un 1 por ciento de TNS patológicos y se trataba de una gestación de 41 semanas. Ningún test de Apgar fue inferior a 8 a los 5 min. En nuestro medio, la monitorización fetal no estresante resulta innecesaria en embarazos de bajo riesgo obstétrico antes de la 40 semana de gestación, ya que no aporta beneficios en la valoración del estado del bienestar fetal (AU)

Neuroblastoma quísticosuprarrenal identificadomediante ecografía prenatal / Adrenal cystic neuroblastoma identified by prenatal echography

El neuroblastoma es el tumor maligno más frecuente del período neonatal. Su detección mediante ecografía obstétrica, permite realizar un diagnóstico y tratamiento precoz, lo que condicionará un mejor pronóstico. Presentamos un caso de neuroblastoma quístico suprarrenal, detectado mediante ecografía obstétrica en la 34 semana de gestación, así como su seguimiento postnatal (AU)

Infective endocarditis of an interventricular patch caused by Acinetobacter haemolyticus.

A case of infective endocarditis caused by Acinetobacter haemolyticus affecting and interventricular patch is reported. The patient, a 21-year-old man with a Fallot's tetralogy who had undergone cardiovascular surgery several years before, received imipenem and gentamicin for 6 and 4 weeks respectively and showed a good response without needing surgical treatment. Endocarditis by Acinetobacter species is very unusual and, to our knowledge, this is the first reported case of infective endocarditis caused by A. haemolyticus. As the clinical characteristics and the response to antibiotics appear to be similar to those reported for infective endocarditis by Acinetobacter lwoffi, prosthetic infective endocarditis by A. haemolyticus is apparently not always an indication for surgical treatment.

[The advantages of palliative embolization and with preoperative ethanol in hypernephroma]. / Ventajas de la embolización con etanol prequirúrgico y paliativa en hipernefromas.

We report thirty-one embolizations of renal cell carcinomas, using ethanol injected through a balloon-tipped catheter. This technique is performed both as a palliative and as a preoperative treatment. Renal function (urea and creatinine) before and a week after embolization showed no important variations. The CT scan six days after embolization disclosed intratumoral gas formation due to necrosis, without infection. Less time and fewer transfusions were required with this procedure and the morbidity and mortality rates were lower. There were no major complications and the duration of the postembolization syndrome was reduced to 48 hours. A histopathological examination of the tumor and the vascular changes was done, showing the effects of ethanol on the arterial and venous walls.

[A suicide attempt with oral verapamil: a case report]. / Intento de autólisis con verapamilo oral: presentación de un caso.

We report a case of a 29-years-old patient who tried to commit suicide by taking a high dose of verapamil (22 pills containing 240 mg, each, equivalent to 5.28 g). Ten hours after the ingestion he presented a complete atrioventricular heart block which was resolved with medical treatment presenting a normal ECG 36 hours later. To our knowledge this is the only published case of intoxication caused by such a high dose of verapamil.

[Spontaneous calcific embolization in calcified aortic valve stenosis. A case report]. / Embolia cálcica espontánea en la estenosis valvular aórtica calcificada. Presentación de un caso.

Calcific embolism from an aortic stenosis is an uncommon event that can be seen after cardiac surgery or left heart catheterization but extremely rare in a spontaneous way. We report a case of a patient with calcified aortic stenosis presenting a spontaneous calcareous embolism in the retinal artery. We review the literature about this problem as well.

[The long-term evolution of patients with senile aortic stenosis undergoing percutaneous valve dilatation]. / Evolución a largo plazo de los pacientes con estenosis aórtica senil sometidos a dilatación valvular percutánea.

The long-term follow-up of 35 patients with mean age of 74.3 +/- 8 years (64-86) who underwent percutaneous aortic valvuloplasty (PAV) is presented. The mean duration of the follow-up study was 33 months (range 1-48). Global mortality was 42% (14 patients) and was related to post-PAV aortic valvular area (47% mortality in less than 0.7 cm2 area group vs 28% in greater than or equal to 0.7 cm2 group) and left ventricular ejection fraction (67% in EF less than 35% group vs 35% in EF greater than or equal to 35% group). The actuarial probability of remaining alive and free of symptoms and of cardiac surgery or new PAV was 57, 41, 33, and 20% at 1, 2, 3 and 4 years. After PAV clinical improvement was obtained in most of the patients (68%), but only 42% of those with successful dilatation remain asymptomatic after a 24 months period (85 +/- 28 mmHg, p = NS). Transvalvular gradient studied by Doppler decreased immediately after PAV (92.8 +/- 26 mmHg vs 51 +/- 16 mmHg, p less than 0.001), but returned to baseline values after 12 months. These results show that PAV yields a clinical improvement in most of the patients, but this improvement is transitory, does not modify the natural history of the disease and has a high degree of restenosis. Thus, its use must be limited to a reduced group of patients who are not candidates for cardiac surgery.