Trombectomía mecánica en la tromboembolia pulmonar aguda de riesgo intermedio-alto / Aspiration thrombectomy for acute pulmonary embolism with an intermediate-high risk

Introducción y objetivo:El tratamiento de la tromboembolia pulmonar (TEP) aguda con riesgo de mortalidad intermedio-alto a los 30 días, sigue sin estar bien definido, recomendándose por las últimas guías clínicas de la European Society of Cardiology2019 el tratamiento anticoagulante exclusivamente, reduciendo la indicación de trombectomía mecánica a pacientes de riesgo alto o pacientes con riesgo intermedio-alto con mala evolución hemodinámica. Nuestro objetivo fue comprobar la mejoría ecocardiográfica, respiratoria y hemodinámica en las primeras horas de los pacientes sometidos a trombectomía mecánica con tromboembolia pulmonar de riesgo intermedio-alto.Material y métodos:Se analizó la evolución cardíaca por ecocardiografía (diámetro de ventrículo derecho, TAPSE, Onda S e hipertensión pulmonar), hemodinámica, respiratoria y clínica de los pacientes en las primeras 24 horas tras trombectomía mecánica por aspiración, así como las complicaciones hemorrágicas y mortalidad del procedimiento.Resultados:Se llevaron a cabo 42 trombectomías mecánicas, 16 con inestabilidad hemodinámica (TEP masivo) y 26 estables hemodinámicamente (TEP submasivo). Se obtuvo mejoría (p<0,05) en el diámetro de ventrículo derecho, TAPSE, Onda S y presión arterial oxígeno/fracción inspiratoria de oxígeno (PaFi). Ocho pacientes recibieron tratamiento fibrinolítico, presentando 4 de ellos (50%) complicaciones hemorrágicas. Solo un paciente presentó complicación directa por el procedimiento (rotura arteria pulmonar). Ocho pacientes fallecieron en la fase aguda de la enfermedad.Conclusiones:La trombectomía mecánica por aspiración es una técnica segura y efectiva, observando una mejoría de la situación respiratoria, hemodinámica y ecocardiográfica de los pacientes en las primeras 24 horas postprocedimiento con baja tasa de complicaciones frente al tratamiento fibrinolítico. (AU)

Introduction and purpose:The treatment of acute pulmonary embolism (PE) with an intermediate-high risk of mortality at 30 days is still not well defined, recommending the latest clinical guidelines of the European Society of Cardiology 2019 exclusively anticoagulant treatment, reducing the indication for mechanical thrombectomy to high-risk patients or intermediate-high risk patients with poor hemodynamic evolution. Our purpose is to determine the safety and efficacy of aspiration thrombectomy in intermediate-high risk patients with PE and to analyze possible differences in these results between hemodynamically unstable patients (massive PE) and hemodynamically stable patients (submassive PE).Methods:We analyzed all patients who underwent aspiration thrombectomy for PE at our tertiary university hospital during a 34-month period. We compared echocardiographic parameters (right ventricular diameter, tricuspid plane annular plane systolic excursion (TAPSE), S′ wave, and pulmonary hypertension), respiratory parameters (PaO2/FiO2 ratio), and clinical parameters recorded before and 24h after the procedure. We also analyzed bleeding complications and mortality.Results:In the 42 patients included (16 with massive PE and 26 with submassive PE), aspiration thrombectomy resulted in significant improvements in right ventricular diameter, TAPSE, S′ wave, andPaO2/FiO2 ratio. Of the 8 patients administered fibrinolysis, 4 developed bleeding complications. Only one direct complication of the procedure was observed (pulmonary artery rupture). Eight patients died in the acute phase.Conclusions:Aspiration thrombectomy for PE is safe and effective, significantly improving respiratory and hemodynamic parameters in the first 24h after the procedure with a low rate of complications compared to fibrinolysis. (AU)

Very High-Frequency Ultrasonography Signs in Bilateral Acute Choroidal Effusion Associated with Systemic Sulphonamide Medications: 2 Cases.

Sulphonamides are commonly used in medicine for several purposes; however, they can lead to significant adverse effects, including idiosyncratic reactions and choroidal detachment corresponding to a forward rotation of the iris-lens diaphragm; this could also evolve into acute transient myopia with possible acute angle closure glaucoma. The risk of such reactions to sulphonamides is approximately 3%. In our communication, we have reported on 2 cases involving patients who suffered choroidal detachments after starting sulphonamide treatments and who were diagnosed with the help of ultrasound biomicroscopy. Patient 1 was an 87-year-old male with bilateral pseudophakia who developed an acute change in vision in both eyes after he started taking chlorthalidone, a classic thiazide diuretic antihypertensive that is characterized by having a sulpha-based group. Patient 2 was a 42-year-old female who developed dramatic visual loss after beginning a new treatment (topiramate) for weight loss. We were able to successfully detect the choroidal detachments in these patients with ultrasound biomicroscopy, which aided us in quickly diagnosing the condition. Subsequently, the drugs were immediately discontinued, and appropriate treatment was administered resulting in the full recovery of both patients.

[Aspiration thrombectomy for acute pulmonary embolism with an intermediate-high risk]. / Trombectomía mecánica en la tromboembolia pulmonar aguda de riesgo intermedio-alto.

INTRODUCTION AND PURPOSE: The treatment of acute pulmonary embolism (PE) with an intermediate-high risk of mortality at 30 days is still not well defined, recommending the latest clinical guidelines of the European Society of Cardiology 2019 exclusively anticoagulant treatment, reducing the indication for mechanical thrombectomy to high-risk patients or intermediate-high risk patients with poor hemodynamic evolution. Our purpose is to determine the safety and efficacy of aspiration thrombectomy in intermediate-high risk patients with PE and to analyze possible differences in these results between hemodynamically unstable patients (massive PE) and hemodynamically stable patients (submassive PE). METHODS: We analyzed all patients who underwent aspiration thrombectomy for PE at our tertiary university hospital during a 34-month period. We compared echocardiographic parameters (right ventricular diameter, tricuspid plane annular plane systolic excursion (TAPSE), S' wave, and pulmonary hypertension), respiratory parameters (PaO2/FiO2 ratio), and clinical parameters recorded before and 24h after the procedure. We also analyzed bleeding complications and mortality. RESULTS: In the 42 patients included (16 with massive PE and 26 with submassive PE), aspiration thrombectomy resulted in significant improvements in right ventricular diameter, TAPSE, S' wave, andPaO2/FiO2 ratio. Of the 8 patients administered fibrinolysis, 4 developed bleeding complications. Only one direct complication of the procedure was observed (pulmonary artery rupture). Eight patients died in the acute phase. CONCLUSIONS: Aspiration thrombectomy for PE is safe and effective, significantly improving respiratory and hemodynamic parameters in the first 24h after the procedure with a low rate of complications compared to fibrinolysis.

Fusarium mycotoxins in total mixed rations for dairy cows.

Mycotoxins produced by certain fungal species of the Fusarium genus are frequently found as contaminants in cereals and feedstuffs. Fumonisins (FBs), deoxynivalenol (DON) and zearalenone (ZEN) are of special concern relative to animal health and productivity. The aim of this work was to analyse the levels of Fusarium mycotoxin contamination in samples of total mixed rations (TMRs) for dairy cows. To accomplish this analysis, an HPLC-MS/MS multi-mycotoxin method was developed and validated. The relation between the formulation of TMR samples and the presence of mycotoxins was also studied. From February 2016 to January 2018, a total of 193 TMR samples for dairy cows collected from farms located in different areas of Spain were analysed for the presence of FBs, ZEN, DON and their metabolites. In total, 112 samples (58%) were contaminated with at least one mycotoxin, and 38 samples (20%) presented more than one mycotoxin. FBs were the mycotoxins most frequently found (34% positive samples). DON was detected in 17% of samples, and ZEN was detected in 16% of samples. Among the metabolites analysed, only deoxynivalenol-3-glucoside (DON-3-Glc) and 15-acetyldeoxynivalenol (15-ADON) were detected. The levels of all the Fusarium mycotoxins studied were always below the values recommended by the European Commission for feedstuffs. The wide variety of ingredients used in the formulation of the analysed samples made it difficult to reach definite conclusions, although it seemed that some cereal silages and concentrates such as cereals or compound feed used as ingredients of the TMR may be related to the presence of mycotoxins.

Aspiration Thrombectomy for Treatment of Acute Massive and Submassive Pulmonary Embolism: Initial Single-Center Prospective Experience.

PURPOSE: To evaluate the feasibility of aspiration thrombectomy in patients with acute massive or submassive pulmonary embolism (PE). MATERIALS AND METHODS: This prospective study analyzed patient demographic data, procedural details, and outcomes in 18 consecutive patients (8 men and 10 women; mean age, 60.1 y; range, 36-80 y), 10 with acute submassive PE and 8 with massive PE, treated with an Indigo Continuous Aspiration Mechanical Thrombectomy Catheter between January 2016 and February 2017. Three patients underwent concomitant systemic fibrinolytic treatment with 100 mg tissue plasminogen activator. Technical success was defined as successful placement of devices and initiation of aspiration thrombectomy. Clinical success was defined as stabilization of hemodynamic parameters; improvement in pulmonary hypertension, right heart strain, or both; and survival to hospital discharge. Complications were also analyzed. RESULTS: The procedure was considered a technical success in 17 patients (94.4%) and a clinical success in 15 (83.3%). Echocardiography showed significant improvements in right ventricle size (46.36 mm ± 2.2 before treatment vs 41.79 mm ± 7.4 after; P = .041), tricuspid annular plane systolic excursion (16 ± 3 before treatment vs 18.57 ± 3.9 after; P = .011), and systolic wave (10 ± 2.1 before treatment vs 13.1 ± 3.8 after; P = .020). Two patients died of massive PE, and 1 died of submassive PE. Two patients who received systemic fibrinolytic agents experienced intracranial bleeding, and abdominal bleeding developed in 1. CONCLUSIONS: Aspiration thrombectomy is a feasible option for the treatment of acute massive or submassive PE in patients with hemodynamic compromise or right ventricular dysfunction.

Documento informado de rechazo de la profilaxis de la enfermedad hemorrágica en neonatos sanos / Briefing Paper of refusal to prophylaxis of hemorrhagic disease in healthy neonates

La Ley 41/2002, básica reguladora de la autonomía del paciente, reconoce que todo paciente o usuario tiene derecho a negarse al tratamiento, siempre y cuando su negativa conste por escrito. En el neonato, las decisiones sobre su salud han de ser tomadas por los padres, debiendo los profesionales que le atiendan durante el proceso asistencial pedir consentimiento a los progenitores antes de proceder a cualquier intervención sobre el recién nacido, incluida la profilaxis de la enfermedad hemorrágica por déficit de vitamina K. El presente artículo presenta dos documentos, ambos elaborados en el Hospital Comarcal da Barbanza (Ribeira, A Coruña): «Instrucción técnica: prevención de la enfermedad hemorrágica del neonato por déficit de vitamina K» y el «Documento informado conforme se rechaza la administración de la profilaxis de la enfermedad hemorrágica por déficit de vitamina K al recién nacido» (AU)

The basic law regulating patients’ autonomy establishes that every patient or user has the right to refuse any treatment through a written notice. As regards neonates, any decision regarding their health has to be taken by their parents, and health professionals working during the care process must seek parental consent prior to any intervention on the neo nate, including the prophylaxis of hemorrhagic disease due to a deficit of vitamin K. This article exhibits two documents, to wit: “Technical training, prevention of hemorrhagic disease of neonates due to a deficit of vitamin K” and “Briefing Paper of refusal to prophylaxis of hemorrhagic disease in healthy neonates” developed at the Hospital Comarcal da Barbanza (Ribeira, A Coruña) (AU)

Determinación del calibre vascular retiniano en hipertensos con un método semiautomático basado en el modelo de snakes / Estimation of the retinal microvascular calibre in hypertensive patients with the snakes semiautomatic model

Fundamento y objetivo: Las guías europeas de hipertensión arterial consideran que es necesario un método que cuantifique de forma objetiva los cambios iniciales en la microcirculación retiniana del hipertenso. Previamente hemos descrito y validado un método semiautomático basado en un modelo lineal, con una alta sensibilidad y especificidad, pero con limitaciones. Fundamento y objetivo: Por este motivo, desarrollamos un método basado en el modelo de snakes, para medir el índice arteriovenoso retininano y lo hemos comparado con el método previamente descrito. Pacientes y método: Para validar este método, hemos analizado las fotografías digitales obtenidas de 173 ojos pertenecientes a un total de 96 pacientes hipertensos; la mayoría de éstos estaban recibiendo tratamiento. Las fotos se han realizado en 2 centros: A Coruña (66) y Santiago de Compostela (107), y la misma persona los ha analizado mediante ambos métodos en cada centro (lineal y snake).Resultados: Hemos observado que las medias y las diferencias de las determinaciones del índice arteriovenoso por ambos métodos son mínimas y siguen una distribución normal. El estadístico alfa de Cronbach fue de 0,974, con un coeficiente de correlación intraclase de 0,949 (p<0,001) para el grupo de imágenes de Santiago, mientras que para el grupo de A Coruña el estadístico alfa de Cronbach fue de 0,923, con un coeficiente de correlación intraclase de 0,857 (p<0,001). Conclusión: Se trata de un método para el cálculo del índice arteriovenoso retiniano de una forma semiautomática, con una elevada sensibilidad y mayor especificidad que el previamente descrito y con una excelente correlación con el anterior (AU)

Background and objective: Early alterations in retinal microcirculation are observed in most hypertensive patients seen in daily practice and the European guidelines consider it is necessary an objective method to quantify these alterations. We have previously described a semi-automatic computerized system to evaluate the calibre of retinal blood vessels that has shown high sensitivity and specificity to calculate the arteriovenous ratio (AVR), though with limitations. We describe a method based on the snakes model to calculate the arteriovenous ratio.Patients and method: We haved compared it with the previously reported lineal method, and we have analyed 173 digital photographs from 96 hypertensive patients, most of them reciveing treatment. Photos were made in two hospitals (A Coruña: 66 and Santiago de Compostela: 107), and were analysed by the same people in each Centre, by the lineal and snake method. Results: We have observed that the arithmetic mean and the differences in AVR between both methods were minimal and showed a normal distribution. Cronbach statistics was 0.974 and intraclass correlation coefficient 0.949 (p<0.001), for the images from Santiago and 0.923 with an intraclass correlation coefficient of 0.857 (p<0.001) for the images from A Coruña. Conclusion: This semiautomatic method to calculate the AVR ratio has a high sensitivity and a greater specificity than previous method, and the correlation between the results obtained with both is excellent (AU)

[Estimation of the retinal microvascular calibre in hypertensive patients with the snakes semiautomatic model]. / Determinación del calibre vascular retiniano en hipertensos con un método semiautomático basado en el modelo de snakes.

BACKGROUND AND OBJECTIVE: Early alterations in retinal microcirculation are observed in most hypertensive patients seen in daily practice and the European guidelines consider it is necessary an objective method to quantify these alterations. We have previously described a semi-automatic computerized system to evaluate the calibre of retinal blood vessels that has shown high sensitivity and specificity to calculate the arteriovenous ratio (AVR), though with limitations. We describe a method based on the snakes model to calculate the arteriovenous ratio. PATIENTS AND METHOD: We had compared it with the previously reported lineal method, and we have analyzed 173 digital photographs from 96 hypertensive patients, most of them receiving treatment. Photos were made in two hospitals (A Coruña: 66 and Santiago de Compostela: 107), and were analysed by the same people in each Centre, by the lineal and snake method. RESULTS: We have observed that the arithmetic mean and the differences in AVR between both methods were minimal and showed a normal distribution. Cronbach statistics was 0.974 and intraclass correlation coefficient 0.949 (p<0.001), for the images from Santiago and 0.923 with an intraclass correlation coefficient of 0.857 (p<0.001) for the images from A Coruña. CONCLUSION: This semiautomatic method to calculate the AVR ratio has a high sensitivity and a greater specificity than previous method, and the correlation between the results obtained with both is excellent.

Enzymatic vitreolysis.

In the absence of posterior vitreous detachment, vitreous cortex is adhered to the internal limiting lamina of the inner retina. This junction between the vitreous and the retina is thought to participate in the pathophysiology of diverse retinal diseases, including proliferative diabetic retinopathy and diabetic macular edema. Vitrectomy has been associated with decrease of macular edema and improvement of visual acuity in eyes of diabetic patients. Thus, many pharmacologic agents have been studied with the aim of inducing a posterior vitreous detachment in order to facilitate the surgical procedure and reduce complications of vitrectomy. More recently, different agents such as plasmin and microplasmin have shown to be able to induce a posterior vitreous detachment given as a single intravitreal injection. The aim of this article is to give a scope about the pharmacologic vitreolysis and posterior vitreous detachment studies and describe some ongoing clinical trials that will determine the efficacy and safety of these novel therapies for diabetic retinopathy.