Alteraciones neuropsicológicas en pacientes en tratamiento con diálisis peritoneal / Neuropsychological impairments in patients undergoing peritoneal dialysis treatment

Objetivo: Los pacientes con enfermedad renal crónica (ERC) en hemodiálisis (HD) suelen presentar déficits cognitivos. Sin embargo, existen pocos estudios que hayan examinado el funcionamiento neuropsicológico de aquellos que reciben diálisis peritoneal (DP). Método: Se evaluaron las funciones ejecutivas, la velocidad de procesamiento y la memoria verbal en 27 pacientes en DP, 42 en HD y 42 participantes sanos (PS). La presión sanguínea sistólica y el tiempo total en terapia renal sustitutiva (TRS) se controlaron estadísticamente. Las asociaciones entre el rendimiento y los factores clínicos se analizaron mediante correlaciones y regresión múltiple. Resultados: El grupo DP presentó mejor ejecución respecto al HD en fluidez verbal, memoria de trabajo, flexibilidad cognitiva, planificación y toma de decisiones. El grupo DP mostró peor ejecución que el grupo PS en inhibición y memoria verbal. Las puntuaciones en las funciones ejecutivas se asociaron positivamente con los meses totales en DP, en TRS, en HD, la albúmina, el colesterol total y el fósforo, y de forma negativa con la ferritina. Conclusión: El funcionamiento ejecutivo global fue mejor en los pacientes en DP que en aquellos en HD. Los resultados muestran el efecto positivo de la DP sobre las funciones ejecutivas, lo que debe tenerse en cuenta a la hora de la elección de la TRS. Las asociaciones observadas entre los factores bioquímicos y el rendimiento muestran la importancia de mantener un adecuado estado nutricional en estos pacientes.(AU)

Background: Patients with chronic kidney disease on hemodialysis (HD) often have cognitive deficits. However, there are few studies that have examined the neuropsychological impairments of patients receiving peritoneal dialysis (PD). Methods: Executive functions, processing speed and verbal memory were assessed in 27 PD patients, 42 HD patients, and 42 healthy participants (HP). Systolic blood pressure and total time on renal replacement therapy (RRT) were controlled statistically. Associations between performance and clinical factors were analyzed using correlations and multiple regression. Results: The DP group showed better performance compared to the HD group in verbal fluency, working memory, cognitive flexibility, planning and decision making. The DP group showed worse execution than the HP group in verbal inhibition and memory. Executive function scores were positively associated with total months on PD, total months on RRT, total months on HD, albumin, total cholesterol, and phosphorus, and negatively with ferritin. Conclusion: Global executive functioning was more optimal in PD patients than in HD patients. The results show the positive effect of PD on executive functions, which must be taken into account when choosing the TRS. The associations observed between biochemical factors and performance show the importance of maintaining an adequate nutritional status in these patients.(AU)

[Neuropsychological impairments in patients undergoing peritoneal dialysis treatment]. / Alteraciones neuropsicológicas en pacientes en tratamiento con diálisis peritoneal.

BACKGROUND: Patients with chronic kidney disease on hemodialysis (HD) often have cognitive deficits. However, there are few studies that have examined the neuropsychological impairments of patients receiving peritoneal dialysis (PD). METHODS: Executive functions, processing speed and verbal memory were assessed in 27 PD patients, 42 HD patients, and 42 healthy participants (HP). Systolic blood pressure and total time on renal replacement therapy (RRT) were controlled statistically. Associations between performance and clinical factors were analyzed using correlations and multiple regression. RESULTS: The DP group showed better performance compared to the HD group in verbal fluency, working memory, cognitive flexibility, planning and decision making. The DP group showed worse execution than the HP group in verbal inhibition and memory. Executive function scores were positively associated with total months on PD, total months on RRT, total months on HD, albumin, total cholesterol, and phosphorus, and negatively with ferritin. CONCLUSION: Global executive functioning was more optimal in PD patients than in HD patients. The results show the positive effect of PD on executive functions, which must be taken into account when choosing the TRS. The associations observed between biochemical factors and performance show the importance of maintaining an adequate nutritional status in these patients.

A Case-Control Study of Cognitive Function in Patients with End-Stage Renal Disease Before and After Hemodialysis in Southern Spain.

BACKGROUND Cognitive problems are frequent in patients with end-stage renal disease (ESRD) treated with hemodialysis. However, previous studies used only a single cognitive screening test or a small number of cognitive indices, which is inadequate for an exhaustive evaluation of cognitive deficits. This case-control study aimed to evaluate cognitive function in patients with ESRD before and after hemodialysis at centers in southern Spain, and included analysis of associations between cognitive function and duration of hemodialysis, biochemistry, body composition, and treatment variables. MATERIAL AND METHODS Cognitive performance was evaluated in 42 healthy participants (HPs) and in 43 ESRD patients, before and after hemodialysis. The tests measured verbal and visual memory, sustained/selective attention, and processing speed. The diagnostic criterion for ESRD was a glomerular filtration rate.

Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery / Necesidad de recolocación de la cabeza y el cuello para revertir alteraciones neurofisiológicas intraoperatorias en el posicionamiento para cirugía de mielopatía cervical

Objective: To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy.Material and methods: We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients’ positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50–80% attenuation of MEP.Results: Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives.Conclusion: Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after(AU)

Objetivo: Evaluar la incidencia de alteraciones neurofisiológicas intraoperatorias graves en el momento del posicionamiento del paciente, y la efectividad de la recolocación del cuello para revertir dichos cambios en los pacientes que se intervienen de mielopatía cervical.Material y métodos: Se empleó una monitorización intraoperatoria multimodal (potenciales evocados sensoriales [PES], motores [PEM] y electromiografía) antes y después de colocar al paciente en posición, en una cohorte de 103 pacientes consecutivos operados de mielopatía cervical. Se consideraron cambios significativos (de alarma): una disminución >50% de la amplitud o un aumento >10% de la latencia de los PES, o la abolición o disminución >50-80% en amplitud de los PEM.Resultados: De los 103 pacientes (el 34,9% mujeres, mediana de edad: 54,5 años), a 88 se les realizó laminectomía (85,4%) y a 15 (14,6%) un abordaje anterior. En el momento del posicionamiento, ocurrieron alteraciones de señal en 44 pacientes (42,7%), aunque solo en 11 (10,7%) estas fueron significativas. La recolocación inmediata del cuello consiguió revertir la alteración de señal completa (n=6) o parcialmente (n=4), sin producirse déficits postoperatorios. El paciente en el cual la recolocación no consiguió restaurar los potenciales despertó con déficit neurológico añadido. La precisión (verdaderos positivos+verdaderos negativos) de la monitorización intraoperatoria para detectar déficits postoperatorios fue del 99% (102/103) para la cohorte completa y del 100% (11/11) para el subgrupo con alteraciones significativas. Globalmente, solo un paciente, que mostró cambios no significativos, despertó con nuevo déficit neurológico (0,97% de falsos negativos).Conclusión: El 10,7% de los pacientes intervenidos de mielopatía cervical mostraron cambios neurofisiológicos de alarma en el momento del posicionamiento quirúrgico. La inmediata recolocación del cuello revirtió dichos cambios (completa o parcialmente)(AU)

Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery.

OBJECTIVE: To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. MATERIAL AND METHODS: We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP. RESULTS: Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. CONCLUSION: Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.

A Brief Review on Gender Differences in Mexican-Mestizo Patients with Pulmonary Arterial Hypertension (PAH) at a Tertiary-Level Hospital.

Pulmonary hypertension (PH) is a hemodynamic condition with different etiological groups but common pathophysiology. Gender differences have been studied in group 1 of the PH classification, the pulmonary arterial hypertension (PAH) group. PAH has an etiopathogenic basis in sex hormones and directly affects the pulmonary vasculature and the heart. Gender differences are observed before and after the age of 45 when women lose the cardioprotective effect of estrogen. A retrospective cohort study in adult patients ≤45 years and >45 years. We compared hemodynamic, echocardiographic, and imaging variables that demonstrated gender differences in adult patients with PAH below and above 45 years. Gender differences in adults ≤45 years were significant for the pronounced pulmonic component of the second heart sound (P2) and the right atrium pressure, on the other hand, more significant sex differences were observed in patients over 45 years of age including the pronounced pulmonic component of P2 (greater in women), the brain natriuretic peptide had a higher median in men, the same happened in the echocardiographic data referring to the area of the right atrium and tricuspid annular plane systolic excursion, abnormal values predominate in men. Although PAH has greater incidence and prevalence in women, the lesions corresponding to cardiac remodeling that subsequently led to right ventricular failure are more remarkable in men, raising their mortality. These findings help recognize its clinical usefulness and propose new research studies aimed at mortality and new pharmacological therapies that might unveil the pathophysiological mechanisms to treat PAH.

Angiographically occult and spontaneously thrombosed large brain arteriovenous malformation / Malformación arteriovenosa cerebral grande, angiográficamente oculta y espontáneamente trombosada

Treatment for brain arteriovenous malformations (AVM) include combinations of surgery, radiosurgery and embolization. Very rarely, spontaneous obliteration may occur, especially among small lesions with single superficial vein drainage and prior bleeding. We report the case of a large symptomatic AVM, without history of hemorrhage or prior treatment, in which self-obliteration was noted at surgery. Although MRI suggested the presence of an AVM, no evidence of arterial anomaly was observed in the brain angiography. At surgery, a large cortical nidus with tortuous arterial vessels, resembling that of an AVM but without blood flow, was identified. Complete resection was easily performed without relevant bleeding. The histopathologic study confirmed the diagnosis of a thrombosed AVM. Despite the low probability of recanalization, surgical resection of a suspected spontaneously obliterated AVM may be warranted, in order to reach a definitive diagnosis and to avoid the risk of an eventual bleeding, especially among younger patients (AU)

El tratamiento de las malformaciones arteriovenosas (MAV) cerebrales incluye combinaciones de cirugía, radiocirugía y embolización. Muy rara vez, ocurre una obliteración espontánea, fundamentalmente en MAV pequeñas, con drenaje venoso único superficial y antecedente de sangrado previo. Presentamos un caso de MAV sintomática grande, sin sangrado ni tratamientos previos, en la que se constató auto-trombosis espontánea. Aunque las imágenes de resonancia sugerían la presencia de una MAV, la arteriografía no mostró anomalía arterial compatible. En la cirugía se evidenció un nidus cortical con vasos tortuosos, idéntico a una MAV clásica, aunque sin flujo sanguíneo, por lo que pudo resecarse sin dificultad. La anatomía patológica confirmó la presencia de una MAV trombosada. A pesar del relativamente bajo riesgo de recanalización, la cirugía de una posible MAV trombosada puede ser una opción recomendable, con objeto de llegar al diagnóstico definitivo y evitar un eventual riesgo de sangrado, especialmente en personas jóvenes (AU)

Dos décadas de análisis de las peritonitis en diálisis peritoneal en Andalucía: aspectos epidemiológicos, clínicos, microbiológicos y evolutivos / Two decades of analysis of peritonitis in peritoneal dialysis in Andalusia: Epidemiological, clinical, microbiological and progression aspects

Antecedentes: Este estudio se centra en la principal complicación asociada a diálisis peritoneal, la peritonitis. Su relevancia deriva de su elevada morbilidad, el efecto negativo que provoca en el peritoneo como membrana de diálisis y de coste económico que ocasiona. Métodos: Estudio observacional de cohortes, analítico, no intervencionista, cuyo objetivo principal es el análisis de las peritonitis en pacientes en diálisis peritoneal, en Andalucía en el periodo: 1 de enero de 1999 a 31 de diciembre de 2017, con un total de 2.904 peritonitis. La base de datos utilizada es la del Sistema de Información de la Coordinación Autonómica de Trasplantes de Andalucía (SICATA). Objetivos: Conocer la evolución de la tasa de peritonitis en nuestra comunidad, analizar datos descriptivos relacionados con los pacientes y las peritonitis, conocer la evolución de estas complicaciones infecciosas y analizar los factores que influyen en estas peritonitis y en su evolución: germen, hospitalización y fecha. Resultados: La tasa de peritonitis ha disminuido progresivamente durante el periodo de estudio desde 0,7 peritonitis por paciente en 1999 hasta 0,33 al final del periodo. La mayoría de las infecciones se tratan de manera ambulatoria (72,5%). Los gérmenes más frecuentes fueron los grampositivos (55,9%), y entre ellos, los estafilococos coagulasa negativos (28,1%). La mayoría de las peritonitis evolucionan a la curación (77,8%). Los factores que influyen de manera significativa en la necesidad de hospitalización y en la evolución de la peritonitis son el germen causal y la presencia de infección del orificio de salida asociado. Conclusiones: En nuestra población, la tasa de peritonitis ha disminuido progresivamente durante el periodo de estudio, alcanzando las recomendaciones de las guías. (AU)

Background: This study focuses on the main complication associated with peritoneal dialysis, peritonitis. Its relevance derives from its high morbidity, the negative effect it has on the peritoneum as a dialysis membrane and its financial cost. Methods: Analytical, non-interventional, observational cohort study, whose main objective is the analysis of peritonitis in patients on peritoneal dialysis in Andalusia from 1 January 1999 to 31 December 2017, with a total of 2,904 peritonitis cases. The database used is the Andalusian Autonomous Transplant Coordination Information System (SICATA). Objectives: To ascertain how the rate of peritonitis is evolving in our community, analyse descriptive data pertaining to patients and peritonitis, ascertain the course of these infectious complications and analyse the factors that influence these cases of peritonitis and their outcomes: germ, hospitalisation and date. Results: The rate of peritonitis decreased progressively during the study period, from 0.7 peritonitis per patient in 1999 to 0.33 at the end of the period. Most infections were treated on an outpatient basis (72.5%). The most common germs were Gram-positive (55.9%), including coagulase-negative staphylococci (28.1%). Most cases of peritonitis progressed to healing (77.8%). The factors that significantly influence the need for hospitalisation and peritonitis progression were the causative germ and associated exit site infection. Conclusions: In our population, the rate of peritonitis decreased progressively during the study period, meeting guideline recommendations. (AU)

Need for head and neck repositioning to restore electrophysiological signal changes at positioning for cervical myelopathy surgery.

OBJECTIVE: To evaluate the incidence of significant intraoperative electrophysiological signal changes during surgical positioning, and to assess the effectiveness of head and neck repositioning on the restoration of signals, among patients undergoing surgery for cervical myelopathy. MATERIAL AND METHODS: We used multimodal intraoperative monitoring (somatosensory [SEP] and motor evoked potentials [MEP] and spontaneous electromyography) before and after patients' positioning in a consecutive cohort of 103 patients operated for symptomatic cervical myelopathy. Significant changes were defined as>50% attenuation in amplitude or>10% increase in latency of SEP, or abolishment or 50-80% attenuation of MEP. RESULTS: Out of 103 patients (34.9% female, median age 54.5 years) 88 underwent laminectomy (85.4%) and 15 (14.6%) anterior approach. At the time of positioning, signal alterations occurred in 44 patients (42.7%), yet only 11 patients (10.7%) showed alarming changes. Immediate neck repositioning of these resulted in complete (n=6) or partial (n=4) restoration of potentials, yielding no postoperative deficits. The patient in which signals could not be restored after repositioning resulted in added postoperative deficit. The accuracy (true positives plus true negatives) of monitoring to detect new neurological deficits was 99.0% (102/103) for the entire cohort, and 100% (11/11) for those showing significant changes at the moment of positioning. Overall, only 1 patient, with non-significant SEP attenuation, experienced a new postoperative deficit, yielding a 0.97% rate of false negatives. CONCLUSION: Among patients undergoing surgery for cervical myelopathy, 10.7% showed alarming electrophysiological signal changes at the time of positioning. Immediate repositioning of the neck resulted in near always restoration of potentials and avoidance of added neurological damage. Complete or partial restoration of potentials after repositioning yielded no postoperative deficits.

Importancia de la arteriografía cerebral y la monitorización neurofisiológica intraoperatoria en la endarterectomía carotídea / Importance of cerebral angiography and intraoperative neuromonitoring in carotid endarterectomy

Cada vez es más frecuente indicar una endarterectomía carotídea en función de la información proporcionada por pruebas no invasivas, como la eco-Doppler, la angio-RM o la angio-TAC, obviando la necesidad de la arteriografía. Presentamos un caso de estenosis carotídea sintomática izquierda del 80% en la que la arteriografía cerebral constató la ausencia del segmento A1 derecho y llenado del territorio cerebral anterior bilateral solo desde el lado izquierdo. A los 90 segundos del pinzamiento de las arterias en el cuello se produjo una disminución brusca de la oximetría cerebral y de la amplitud de los potenciales somatosensoriales, que cedieron tras el despinzamiento inmediato. Se desestimó realizar la endarterectomía y se colocó un stent carotídeo sin complicaciones. Este caso ejemplifica la importancia de conocer el estado de la circulación cerebral distalmente a la estenosis. De haberse intentado realizar la endarterectomía sin tener en cuenta la información proporcionada por la arteriografía, posiblemente habría ocurrido una isquemia bihemisférica grave (AU)

It is an increasingly common practice to indicate a carotid endarterectomy procedure based on the information provided by non-invasive tests like Duplex ultrasound, MR angiography or CT angiography, thereby obviating the performance of a conventional cerebral angiography. We present a case of symptomatic left carotid artery 80% stenosis in which cerebral angiography showed absence of the right A1 segment and bilateral anterior cerebral artery territories that filled only from a left injection. Just 90 seconds after carotid artery clamping at the neck, brain oximetry and somatosensory evoked potentials significantly dropped, that recovered after immediate clamp removal. Endarterectomy was dismissed and a carotid stent was successfully placed. This case highlights the importance of knowing the dynamics of cerebral blood circulation distal to the stenosis. If endarterectomy had been attempted, unawareness of the information provided by the cerebral angiography would have likely result in severe bi-hemispheric ischemia (AU)

Volumetric growth rate of incidental asymptomatic meningiomas: a single-center prospective cohort study.

BACKGROUND: Decision about treatment of incidentally found intracranial meningiomas is controversial and conditioned by the growth potential of these tumors. We aimed to evaluate the growth rate of a cohort of incidentally found asymptomatic meningiomas and to analyze their natural course and the need for eventual treatment. METHODS: A total of 193 patients harboring intracranial meningiomas (85 with 109 incidental and 108 with 112 symptomatic) were included between 2015 and 2019. In the prospective cohort of incidental meningiomas, we measured size at diagnosis, volumetric growth rate (by segmentation software), appearance of symptoms, and need for surgery or radiotherapy. Progression-free survival and risk factors for growth were assessed with Kaplan-Meier survival and Cox regression analyses. RESULTS: Among incidental meningiomas, 94/109 (86.2%) remained untreated during a median follow-up of 49.3 months. Tumor growth was observed in 91 (83.5%) and > 15% growth in 40 (36.7%). Neurological symptoms developed in 1 patient (1.2%). Volume increased an average of 0.51 cm3/year (95% CI, 0.20-0.82). Nine patients were operated (9.2%) and 4 underwent radiotherapy (4.7%). Treatment-related complication rates of incidental and symptomatic meningiomas were 0% and 35.4%, respectively. Persistent neurological defects occurred in 46 (40.7%) of symptomatic versus 2 (2.3%) of incidental meningiomas. Among covariates, only brain edema resulted in an increased risk of significant tumor growth in the female subgroup (Cox regression HR 2.96, 95% CI 1.02-8.61, p = 0.046). Size at diagnosis was significantly greater in the symptomatic meningioma group (37.33 cm3 versus 4.74 cm3, p < 0.001). CONCLUSIONS: Overall, 86% of incidentally found meningiomas remained untreated over the first 4 years of follow-up. The majority grew within the 20% range, yet very few developed symptoms. Treatment-related morbidity was absent in the incidental meningioma group.

Two decades of analysis of peritonitis in peritoneal dialysis in Andalusia: Epidemiological, clinical, microbiological and progression aspects.

BACKGROUND: This study focuses on the main complication associated with peritoneal dialysis, peritonitis. Its relevance derives from its high morbidity, the negative effect it has on the peritoneum as a dialysis membrane and its financial cost. METHODS: Analytical, non-interventional, observational cohort study, whose main objective is the analysis of peritonitis in patients on peritoneal dialysis in Andalusia from 1 January 1999 to 31 December 2017, with a total of 2904 peritonitis cases. The database used is the Andalusian Autonomous Transplant Coordination Information System (SICATA). OBJECTIVES: To ascertain how the rate of peritonitis is evolving in our community, analyse descriptive data pertaining to patients and peritonitis, ascertain the course of these infectious complications and analyse the factors that influence these cases of peritonitis and their outcomes: germ, hospitalisation and date. RESULTS: The rate of peritonitis decreased progressively during the study period, from 0.7 peritonitis per patient in 1999 to 0.33 at the end of the period. Most infections were treated on an outpatient basis (72.5%). The most common germs were Gram-positive (55.9%), including coagulase-negative staphylococci (28.1%). Most cases of peritonitis progressed to healing (77.8%). The factors that significantly influence the need for hospitalisation and peritonitis progression were the causative germ and associated exit site infection. CONCLUSIONS: In our population, the rate of peritonitis decreased progressively during the study period, meeting guideline recommendations.

Reliability and accuracy of individual Alberta Stroke Program Early CT Score regions using a medical and a smartphone reading system in a telestroke network.

INTRODUCTION: The aim of this study was to assess individual regions of the Alberta Stroke Program Early CT Score in noncontrast head computed tomography interpretations using a smartphone in a telestroke network, by comparison to a medical monitor. METHODS: The review board of our institution approved this retrospective study. A factorial design with 188 patients, four radiologists and two reading systems was used. Accuracy and reliability were evaluated. RESULTS: Very good interobserver agreements were observed on the total Alberta Stroke Program Early CT Score for both the medical and smartphone reading systems, with intraclass correlation coefficients of 0.91 and 0.84 respectively. Interobserver agreements were moderate to very good for the medical reading system (all intraclass correlation coefficients >0.74), whereas they were fair to very good for the smartphone (intraclass correlation coefficients ranged from 0.31-0.81). All intraobserver agreements were good (intraclass correlation coefficient >0.64), except for internal capsule (0.48) and M2 (0.55) regions. The areas under the receiver-operating curve ranged from 0.69-0.89 for the medical system, while for the smartphone ranged from 0.44-0.86. No statistical differences were observed between medical and smartphone reading systems for each region (all p > 0.05). DISCUSSION: If radiologists are better trained in the evaluation of the lesions in the insula, the internal capsule and the M2 regions, the total and the dichotomised Alberta Stroke Program Early CT Score will be more precise. Hence, ruling out contraindications to thrombolysis administration will be improved, allowing assessment of head computed tomography in a telestroke network using a smartphone to be a common practice.

Importance of cerebral angiography and intraoperative neuromonitoring in carotid endarterectomy. / Importancia de la arteriografía cerebral y la monitorización neurofisiológica intraoperatoria en la endarterectomía carotídea.

It is an increasingly common practice to indicate a carotid endarterectomy procedure based on the information provided by non-invasive tests like Duplex ultrasound, MR angiography or CT angiography, thereby obviating the performance of a conventional cerebral angiography. We present a case of symptomatic left carotid artery 80% stenosis in which cerebral angiography showed absence of the right A1 segment and bilateral anterior cerebral artery territories that filled only from a left injection. Just 90seconds after carotid artery clamping at the neck, brain oximetry and somatosensory evoked potentials significantly dropped, that recovered after immediate clamp removal. Endarterectomy was dismissed and a carotid stent was successfully placed. This case highlights the importance of knowing the dynamics of cerebral blood circulation distal to the stenosis. If endarterectomy had been attempted, unawareness of the information provided by the cerebral angiography would have likely result in severe bi-hemispheric ischemia.

Angiographically occult and spontaneously thrombosed large brain arteriovenous malformation.

Treatment for brain arteriovenous malformations (AVM) include combinations of surgery, radiosurgery and embolization. Very rarely, spontaneous obliteration may occur, especially among small lesions with single superficial vein drainage and prior bleeding. We report the case of a large symptomatic AVM, without history of hemorrhage or prior treatment, in which self-obliteration was noted at surgery. Although MRI suggested the presence of an AVM, no evidence of arterial anomaly was observed in the brain angiography. At surgery, a large cortical nidus with tortuous arterial vessels, resembling that of an AVM but without blood flow, was identified. Complete resection was easily performed without relevant bleeding. The histopathologic study confirmed the diagnosis of a thrombosed AVM. Despite the low probability of recanalization, surgical resection of a suspected spontaneously obliterated AVM may be warranted, in order to reach a definitive diagnosis and to avoid the risk of an eventual bleeding, especially among younger patients.

Comprehensive Telestroke Network to Optimize Health Care Delivery for Cerebrovascular Diseases: Algorithm Development.

BACKGROUND: Health care delivery for cerebrovascular diseases is a complex process, which may be improved using telestroke networks. OBJECTIVE: The purpose of this work was to establish and implement a protocol for the management of patients with acute stroke symptoms according to the available treatment alternatives at the initial point of care and the transfer possibilities. METHODS: The review board of our institutions approved this work. The protocol was based on the latest guidelines of the American Heart Association and American Stroke Association. Stroke care requires human and technological resources, which may differ according to the patient's point of entry into the health care system. Three health care settings were identified to define the appropriate protocols: primary health care setting, intermediate health care setting, and advanced health care setting. RESULTS: A user-friendly web-based telestroke solution was developed. The predictors, scales, and scores implemented in this system allowed the assessment of the vascular insult severity and neurological status of the patient. The total number of possible pathways implemented was as follows: 10 in the primary health care setting, 39 in the intermediate health care setting, and 1162 in the advanced health care setting. CONCLUSIONS: The developed comprehensive telestroke platform is the first stage in optimizing health care delivery for patients with stroke symptoms, regardless of the entry point into the emergency network, in both urban and rural regions. This system supports health care personnel by providing adequate inpatient stroke care and facilitating the prompt transfer of patients to a more appropriate health care setting if necessary, especially for patients with acute ischemic stroke within the therapeutic window who are candidates for reperfusion therapies, ultimately contributing to mitigating the mortality and morbidity associated with stroke.

Polvo de vancomicina tópico para la prevención de infección de herida quirúrgica en cirugía electiva de columna por vía posterior / Vancomycin powder for the prevention of surgical site infection in posterior elective spinal surgery

OBJETIVO: Evaluar la efectividad y seguridad del polvo de vancomicina tópico como profilaxis de infección de herida quirúrgica (IHQ) en cirugía de columna electiva por abordaje posterior. MATERIAL Y MÉTODOS: Estudio unicéntrico cuasiexperimental de comparación pre- y postintervención. El grupo postintervención recibió profilaxis antibiótica estándar preoperatoria junto a 1g de polvo de vancomicina en el lecho quirúrgico antes del cierre de la herida. El grupo preintervención solo recibió la profilaxis intravenosa. RESULTADOS: Participaron 150 pacientes en cada grupo. Ocurrieron 12 infecciones (7 superficiales, 5 profundas) en el grupo postintervención y 16 infecciones (7 superficiales, 9 profundas) en el grupo preintervención. El riesgo de IHQ profunda se redujo del 6% al 3,3% (OR 0,54; IC 95% 0,17-1,65; p = 0,411) con el tratamiento. El porcentaje de IHQ profunda por gramnegativos-positivos fue del 80-20% en el grupo tratado con vancomicina y del 33-67% en los no tratados (p = 0,265). No se produjeron efectos adversos locales ni sistémicos por el tratamiento. CONCLUSIÓN: La profilaxis con polvo de vancomicina en cirugía electiva de columna por abordaje posterior no redujo de forma significativa la incidencia de IHQ superficial o profunda. Se constató una tendencia al aumento de IHQ profunda por microorganismos gramnegativos en los tratados con vancomicina

OBJECTIVE: To assess the effectiveness and safety of vancomycin powder as surgical site infection (SSI) prophylaxis in posterior bilateral elective spinal surgery. MATERIALS AND METHODS: Single-center quasi-experimental pre and postintervention comparative cohort study. The post-intervention group received standard intravenous antibiotic prophylaxis plus 1g of vancomycin powder into the surgical field before wound closure, and the pre-intervention group only the intravenous prophylaxis. RESULTS: 150 patients were included in each group. Twelve SSI (7 superficial and 5 deep) occurred in the post-intervention group and 16 SSI (7 superficial and 9 deep) in the pre-intervention group. The risk of deep SSI decreased from 6.0% to 3.3% (OR 0,54, 95%CI 0.17-1.65, p = 0.411) with vancomycin powder. The percentage of deep SSI due to gram negative-positive germs were 80%-20% and 33%-67% for the post- and pre-intervention groups, respectively (p = 0.265). No local or systemic adverse effects occurred attributable to vancomycin powder. CONCLUSIÓN: In posterior elective spinal surgery, prophylaxis with vancomycin powder did not result in a significantly reduced incidence of superficial and deep SSI. There was a trend towards a higher incidence of deep SSI caused by gram negative microorganisms among those treated with vancomycin

IgA Nephropathy After Renal Transplant: Recurrences and De Novo Cases.

IgA nephropathy (IgAN) recurrence in the renal graft is variable. Several factors can influence the risk of recurrence of IgAN and renal graft failure. We carried out a retrospective observational study between the years 1990 and 2018. The study group was patients diagnosed, by means of biopsy, as having post-renal transplant (RT) IgAN in our hospital in the study period. The control group was patients with pre-RT histologic diagnosis of IgAN who did not develop recurrence of the disease after the RT. A total of 1535 RTs were performed in our center in the study period. Of those, 24 patients developed IgAN in the renal graft. The time elapsed from the RT to the development of allograft IgAN was 7 (SD, 5.3) years. The patients with allograft IgAN tended to be younger (P = .069), and HLA-DR4 was more common in these patients (P = .078). We observed a very significant difference in the use of induction immunosuppressive therapy (study group vs control group: 13.6% vs 57.7%, P < .001). The 3 patients who presented crescents in the biopsy specimen lost the renal graft. As in the native kidney, the presence of crescents is an indicator of poor prognosis. In our experience, the patients with post-RT IgAN received induction therapy less frequently; this finding would support the conclusion that such treatments should be applied to patients with pre-RT diagnosis of IgAN.

Accuracy and Reliability of the Recommendation for IV Thrombolysis in Acute Ischemic Stroke Based on Interpretation of Head CT on a Smartphone or a Laptop.

OBJECTIVE. The objective of this study was to assess the accuracy and reliability of IV thrombolysis recommendations made after interpretation of head CT images of patients with symptoms of acute stroke displayed on smartphone or laptop reading systems compared with those made after interpretation of images displayed on a medical workstation monitor. MATERIALS AND METHODS. This retrospective study was institutional review board-approved, and the requirement for informed consent was waived. We used a factorial design including 2256 interpretations (188 patients, four neuroradiologists, and three reading systems). To evaluate the reliability, we calculated the intraobserver and interobserver agreements using the intraclass correlation coefficient (ICC) and the following interpretation variables: hemorrhagic lesions, intraaxial neoplasm, stroke dating (acute, subacute, and chronic), hyperdense arteries, and infarct size assessment. Accuracy equivalence tests were performed for the IV thrombolysis recommendation; for this variable, sensitivity, specificity, and ROC curves were evaluated. RESULTS. Good or very good interobserver and intraobserver agreements were obtained after interpretation of each variable. The IV thrombolysis recommendation showed very good interobserver agreements (ICC ≥ 0.85) and very good intraobserver agreements (ICC ≥ 0.81). For the IV thrombolysis recommendation, the AUC values (0.83-0.84) and sensitivities (0.94-0.95) were equivalent among all the reading systems at a 5% equivalent threshold. CONCLUSION. Our study found that mobile devices are reliable and accurate to help stroke teams to decide whether to administer IV thrombolysis in patients with acute stroke.

Técnicas abandonadas en cirugía de columna / Abandoned techniques in spine surgery

En cirugía de columna, ciertos dispositivos y algunas técnicas quirúrgicas han sido abandonados por completo o se hallan en franco declive. Aunque empleados en miles de pacientes, dichos tratamientos no han demostrado una efectividad sólida y duradera y, ocasionalmente, asocian morbilidades inaceptables. Ejemplos de abandono son la quimionucleólisis, la discectomía percutánea, la discectomía por láser o los geles antifibrosis. Otras técnicas se encuentran en marcado retroceso como los dispositivos interespinosos o las prótesis discales lumbares. Generalmente una técnica se abandona por falta de efectividad, morbilidad excesiva, sustitución por otra técnica más eficaz y menos agresiva, por falta de comercialización o por prohibición de su uso. En las últimas décadas, la enorme presión comercial y una creciente demanda social han conseguido convencer a muchos cirujanos de columna para que empleen tratamientos no suficientemente sustentados por estudios sólidos ni avalados por el paso del tiempo, muchos de los cuales eventualmente se abandonan

In spine surgery, certain surgical techniques and devices are currently in marked decline or have been completely abandoned. Although used in thousands of patients, such treatments failed to demonstrate durable and sound effectiveness, and sometimes associate inacceptable morbidity. Chemopapain injections, percutaneous discectomy, laser discectomy or antiadhesion gels are examples of abandoned therapies. Some other techniques are in frank decline like implantation of interspinous devices or lumbar disc prosthesis. In general, a technique is abandoned due to inefficacy, excessive associated morbidity, substituted by another more efficacious and less aggressive technique, end of commercialization, or usage prohibition. In the last decades, a great commercial pressure plus an increasing social demand have managed to convince many spine surgeons to indicate treatments not sufficiently supported by scientific evidence nor consolidated over time, many of which are eventually abandoned