Valor adicional de la tecnología híbrida de PET/RM frente a la RM y la PET en la enfermedad cardiovascular / Additional value of hybrid PET/MR imaging versus MR or PET performed separately to assess cardiovascular disease

Introducción y objetivos Los sistemas híbridos de tomografía por emisión de positrones (PET) y resonancia magnética (RM) son una tecnología prometedora para el diagnóstico por imagen, pero su aplicación cardiovascular en nuestro entorno clínico es desconocida. Nuestro objetivo es evaluar el valor de los equipos integrados de PET/RM frente a la RM y la PET por separado. Métodos Se incluyó prospectivamente a 49 pacientes, 30 para valoración de viabilidad miocárdica (grupo coronario) y 19 para estudio de enfermedad inflamatoria, infecciosa y tumoral (grupo no coronario), a los que se realizó una PET/RM cardiaca con 18F-fluorodesoxiglucosa, incluyendo secuencias de corrección de atenuación y, simultáneamente a la PET, secuencias de cine, caracterización tisular o realce tardío de RM, según indicación clínica. Resultados El 87,8% de los estudios de PET/RM fueron inicialmente interpretables. La PET/RM mejoró el diagnóstico en el 42,1% de los pacientes del grupo coronario respecto a la PET o la RM por separado, y en el 88,9% del grupo no coronario. De los casos no concluyentes según la RM o la PET, la PET/RM reclasificó a estudio diagnóstico al 87,5% de los pacientes del grupo coronario y el 70% de los del no coronario. Conclusiones En nuestra serie, la tecnología multimodal de PET/RM añade valor diagnóstico en algunos pacientes con enfermedad cardiovascular, sobre todo en enfermedad no coronaria y con hallazgos no concluyentes por RM o PET, y complementa cada técnica por separado. Los principales beneficios incluyen la adquisición simultánea, la integración de imágenes anatómicas, funcionales y metabólicas y la interacción entre distintos profesionales expertos en imagen. (AU)

Introduction and objectives Hybrid positron emission tomography (PET) and magnetic resonance (MR) imaging is an emerging technology in the diagnosis of cardiovascular disease; however, there have been no reports of its use in the national clinical setting. Our objective was to evaluate the additional value of integrated PET/MR systems compared with MR and PET performed separately in this setting. Methods We prospectively included 49 patients, 30 to assess myocardial viability (coronary group) and 19 to assess inflammatory, infectious, and tumoral diseases (noncoronary heart disease group). All patients underwent cardiac 18F-fluorodeoxyglucose PET/MR. PET/MR studies included attenuation correction sequences, followed by simultaneous cardiac PET and cardiac MR acquisition, with protocols adapted to the clinical indication (cine, tissue characterization and/or late enhancement imaging). Results Most (87.8%) PET/MR studies were initially interpretable. Use of PET/MR improved diagnosis vs PET or MR performed separately in 42.1% of coronary cases and 88.9% of noncoronary cases. PET/MR enabled reclassification of 87.5% of coronary cases initially classified as showing inconclusive results on MR or PET and 70% of noncoronary cases. Conclusions In our series, multimodality PET/MR technology provided additional diagnostic value in some patients with cardiovascular disease compared with MR and PET performed separately, especially in cases of noncoronary heart disease and in those with inconclusive results on MR or PET. In our experience, the main benefits of PET/MR include the possibility of simultaneous acquisition, the in vivo integration of anatomical/functional/metabolic aspects, and the interaction of different experts in imaging modalities. (AU)

Additional value of hybrid PET/MR imaging versus MR or PET performed separately to assess cardiovascular disease.

INTRODUCTION AND OBJECTIVES: Hybrid positron emission tomography (PET) and magnetic resonance (MR) imaging is an emerging technology in the diagnosis of cardiovascular disease; however, there have been no reports of its use in the national clinical setting. Our objective was to evaluate the additional value of integrated PET/MR systems compared with MR and PET performed separately in this setting. METHODS: We prospectively included 49 patients, 30 to assess myocardial viability (coronary group) and 19 to assess inflammatory, infectious, and tumoral diseases (noncoronary heart disease group). All patients underwent cardiac 18F-fluorodeoxyglucose PET/MR. PET/MR studies included attenuation correction sequences, followed by simultaneous cardiac PET and cardiac MR acquisition, with protocols adapted to the clinical indication (cine, tissue characterization and/or late enhancement imaging). RESULTS: Most (87.8%) PET/MR studies were initially interpretable. Use of PET/MR improved diagnosis vs PET or MR performed separately in 42.1% of coronary cases and 88.9% of noncoronary cases. PET/MR enabled reclassification of 87.5% of coronary cases initially classified as showing inconclusive results on MR or PET and 70% of noncoronary cases. CONCLUSIONS: In our series, multimodality PET/MR technology provided additional diagnostic value in some patients with cardiovascular disease compared with MR and PET performed separately, especially in cases of noncoronary heart disease and in those with inconclusive results on MR or PET. In our experience, the main benefits of PET/MR include the possibility of simultaneous acquisition, the in vivo integration of anatomical/functional/metabolic aspects, and the interaction of different experts in imaging modalities.

Experiencia de 30 años en una unidad de diálisis peritoneal: supervivencia a largo plazo / Thirty years in a peritoneal dialysis unit: long-term survival

INTRODUCCIÓN: La diálisis peritoneal (DP) es una técnica establecida de tratamiento renal sustitutivo que gracias a los avances tecnológicos y clínicos ha mejorado sus tasas de supervivencia en los últimos años. OBJETIVOS: Evaluar la supervivencia del paciente y la técnica en DP a lo largo de 30 años y según las décadas para consolidar su utilidad sanitaria. MÉTODOS: Estudio retrospectivo de cohorte de todos los pacientes del programa de DP del Hospital Universitario La Paz (Madrid) desde 1980 a 2010. Variables demográficas y clínicas fueron recolectadas de los registros clínicos. RESULTADOS: Se incluyeron 667 pacientes, 54,4 % varones, con edad media de 51,47 años y una mediana de seguimiento de 23,1 meses. Se observó un aumento progresivo de pacientes incidentes, especialmente en DP automatizada (DPA). La supervivencia del paciente a 5 años fue de 54 %, con una mediana de 64,66 meses, con un aumento significativo en la última década (p = 0,000). La edad, la comorbilidad, el sexo masculino, la DP crónica ambulatoria (DPCA) y la diabetes fueron predictores de la supervivencia del paciente. La supervivencia de la técnica a los 5 años fue del 64,2 % y la mediana de 82 meses. El éxito de la técnica fue mayor en jóvenes, en DPA y con menor comorbilidad

BACKGROUND AND OBJECTIVE: Peritoneal dialysis (PD) is an establish renal replacement therapy that has evolved in the last decades thanks to technological and clinical advances showing improving survival rates. The aim of this study was to evaluate the patient and technique survival in PD over 30 years of experience and in the different decades. PATIENTS AND METHOD: Retrospective cohort study including all patients in the PD unit of the Hospital Universitario La Paz (Madrid), from 1980 to 2010. Demographics and clinical variables were collected from medical records. RESULTS: A total of 667 patients were included, 54.4% males, with a mean age of 51.47 years and a median follow-up of 23.1 months. There was an increased in PD incident patients, especially in automatic PD (APD). Patient survival at 5 years was 54%, with a median of 64.66 months, increasing significantly in the last decade (p = 0.000). Age, comorbidity, male sex, chronic ambulatory PD and diabetes were independently predictor of patient survival. Technique survival at 5 years was 64.2% and median 82 months. Younger patients, in APD and with less comorbity showed better technique survival. CONCLUSIONS: Over 30 years of experience we found an increased in incident patients. Age, comorbidity and diabetes were still the main predictors of survival

Thirty years in a peritoneal dialysis unit: long-term survival.

INTRODUCTION: Peritoneal dialysis (PD) is an established renal replacement therapy technique which thanks to the technological and clinical advances has improved its survival rates in recent years. OBJECTIVES: The aim of this study was to evaluate patient and technique survival in PD over 30 years, according to the different decades in order to consolidate its usefulness in healthcare. METHOD: Retrospective cohort study including all patients in the PD programme of the Hospital Universitario La Paz (Madrid), from 1980 to 2010. Demographic and clinical variables were collected from medical records. RESULTS: A total of 667 patients were included, 54.4% male, with a mean age of 51.47 years and a median follow-up period of 23.1 months. There was a progressive increase in PD incident patients, especially in automated PD (APD). Patient survival at 5 years was 54%, with a median of 64.66 months, increasing significantly in the last decade (P=.000). Age, comorbidity, male sex, chronic ambulatory PD (CAPD) and diabetes were predictors of patient survival. Technique survival at 5 years was 64.2% with a median of 82 months. The success of the technique was greater in younger patients on APD and with lower comorbidity. CONCLUSIONS: Over 30 years, we found an increase in incident patients. Age, comorbidity and diabetes still continue to be the main determining factors for survival.

Survey on the culture of patient safety among Spanish health care residents.

To improve patient safety, it is essential to have knowledge of the attitudes of all those involved in health care. The Thomas Jefferson Survey on Inpatient Adverse Events was translated and validated; all residents in Asturias, Spain, were invited to complete the survey. A total of 359 residents (60%) completed the survey; 50% of those surveyed agreed that adverse events (AEs) can be prevented. A greater percentage of responses attributed more responsibility to patients (54.4%) than to physician errors (28.7%). A total of 72% of respondents had observed AEs over the past 2 months, and 37% would be willing to take part in a work group to improve patient safety. It is necessary to increase residents' involvement in efforts to improve patient safety, so that they will learn how to deal with health care risks and AEs and will share their knowledge and experiences.

Influencia de la inflamación y la presencia de amiloide sobre el metabolismo lipídico en pacientes con artritis reumatoide / No disponible

Introducción Los pacientes con artritis reumatoide (AR) presentan una aterosclerosis acelerada, que se ha relacionado en parte con alteraciones del metabolismo lipídico asociadas al proceso inflamatorio, que incluye a la proteína sérica amiloide A. Objetivo Evaluar el perfil lipídico en pacientes con AR tratada y su relación con la actividad inflamatoria y la presencia de amiloidosis secundaria. Métodos Se estudiaron 78 pacientes mujeres con AR. A todas se les realizó una extracción sanguínea para analizar el perfil lipídico (colesterol total, c-HDL, c-HDL3, c-HDL2, c-LDL, triglicéridos, lipoproteína(a) y (..) (AU)

Introduction Patients with rheumatoid arthritis (RA) display an accelerated atherosclerosis that is related in part to lipid metabolism disorders associated with the inflammatory process, which includes serum amyloid protein A. Objective To evaluate the lipid profile in treated RA patients and its relationship to inflammatory activity and the presence of secondary amyloidosis.

Rapid molecular diagnosis of ataxia-telangiectasia by optimised RT-PCR and direct sequencing analysis.

Ataxia-telangiectasia (A-T) is a severe autosomal recessive disorder involving cerebellar degeneration, immunodeficiency, chromosomal instability, radiosensitivity, and cancer predisposition. A-T results from mutations in a single gene (ataxia-telangiectasia mutated, ATM) on chromosome 11 that encodes a 3056 amino acid protein (ATM). The purpose of this study is the design of an easy and rapid method for the molecular diagnosis of A-T which could be applied to clinical diagnosis, genetic counselling, carrier prediction, and prenatal diagnosis. Sixteen primer pairs were designed for RT-PCR. The PCR conditions were optimised to obtain a unique profile for the amplification of the 16 PCR products. These fragments were purified, directly sequenced and interpreted. The mutations found in three Spanish A-T families were reconfirmed with the optimised PCR and direct sequencing analysis. Up to now more than 400 A-T associated mutations have been reported in the ATM gene that do not support the existence of one or several hotspots. The immense size (transcript with 9168 nucleotides) and the structure of this gene (66 exons) greatly complicate the process of screening for all sequence variations. Our simple method allows identification of mutations in the coding region of the ATM gene from cDNA and represents a very useful tool for early diagnosis and genetic counselling in families with A-T.

Ultrafiltration and small solute transport at initiation of PD: questioning the paradigm of peritoneal function.

BACKGROUND: Human peritoneal function on commencing peritoneal dialysis (PD) is not yet adequately understood. The objective of this study was to determine peritoneal functional patterns on commencing PD. METHODS: 367 end-stage renal disease (ESRD) patients on PD for the first time were studied between their initial second to sixth weeks on PD. Urea and creatinine mass transfer area coefficients (MTAC) and standardized ultrafiltration (UF) capacity were determined. RESULTS: Mean parametric values were MTAC urea 22.9 +/- 7.04 mL/min, MTAC creatinine 10.31 +/- 4.68 mL/min, and UF 896 +/- 344 mL. Gender, patient size, and diabetes or kidney disease did not affect these parameters. The relationship between values of MTAC creatinine and UF reached statistical significance, although with a low value for Pearson's coefficient (r = -0.30, p = 0.001). Age showed a significant inverse linear correlation with UF capacity (r = -0.15, p = 0.003) and MTAC urea (r = -0.11, p < 0.05). Logistic regression analysis demonstrated that UF below 400 mL was independently related to a high MTAC creatinine and older age. Diabetes was least frequent in patients with the lowest UF. However, in the analysis of MTAC creatinine quintiles, UF values did not follow the expected inverse pattern. The lack of differences in UF between the second and third to fourth MTAC creatinine quintiles is remarkable; MTAC creatinine ranged from 6.71 to 13.54. CONCLUSIONS: The functional characteristics of human peritoneum varied markedly and there was a less intense than expected relationship between solute and water transports. This mild inverse relationship is intriguing and suggestive of the necessity of redefining some basic concepts. Age was associated with a lower peritoneal UF capacity, in part independently of small solute transport.

Pathogenic significance of hypertrophic mesothelial cells in peritoneal effluent and ex vivo culture.

The presence of hypertrophic mesothelial cells (HMCs) in peritoneal effluent (PE) has been considered a possible marker for peritoneal sclerosis. We conducted the present study to evaluate if the presence of HMCs in PE or in culture was related to peritoneal function alterations or to the development of sclerosing peritonitis. We prospectively studied 32 new peritoneal dialysis (PD)patients every 4 months, determining the presence of HMCs in culture (completing 129 studies in total). We isolated mesothelial cells from nocturnal PE and cultured them ex vivo in T-25 flasks. Cell morphology was estimated using the May-Grünwald/Giemsa method. We also examined the histories of a large patient group to determine HMCs directly in PE, and we evaluated 4 of those patients (6%) who showed persistent HMCs. In 10 of 32 prospectively studied patients, we found HMCs during the culture phase. The cells appeared in the first evaluation in 4 patients and in subsequent cultures in the remaining 6 patients. Ultrafiltration (UF) and solute transport capacity in the 10 patients were similar to those of patients who did not show HMCs. Demographic parameters were not different between the two groups. None of the prospectively studied patients showed any clinical or peritoneal functional abnormality during the study. Cultures performed after the observation of HMCs showed very poor growth capacity. The evolution of the 4 patients in the historic group occurred as follows: We 1 patient transferred to hemodialysis 2 years after the observation of HMCs. 1 patient died of an unrelated cause after 1 year on PD. 1 patient received a successful kidney graft 5 years after the observation of HMCs. 1 patient developed type I UF failure 10 years after the first observation.

Clinical experience with tamoxifen in peritoneal fibrosing syndromes.

Peritoneal sclerosis is one of the most important complications of peritoneal dialysis (PD) treatment. Encapsulating peritoneal sclerosis (EPS) represents the most advanced stage of that disease and has a high mortality. No therapy of choice has been established for sclerosing peritonitis, although many have been proposed, with variable results. Tamoxifen has been successfully used in the treatment of patients with fibrosing diseases, mainly retroperitoneal fibrosis. Our purpose in the present study was to investigate whether treatment with tamoxifen in PD patients with peritoneal sclerosis has a beneficial effect. Among more than 450 patients treated in our program since 1980, 23 were diagnosed with peritoneal sclerosis. Of those 23.9 were treated with tamoxifen [20 mg every 12 hours: tamoxifen group (TG)] for a mean period of 14.5 +/- 7 months (range: 6-30 months). The other 14 patients received no treatment and were considered the control group (CG). Both groups were similar in demography and peritoneal antecedents. Follow-up was longer in CG than in TG (mean: 47 months vs. 29 months), but the difference did not reach statistical significance. Mild thrombopenia in 1 patient was the only toxic effect observed with the use of tamoxifen. In CG, 4 patients developed EPS and died--3 of them during the first 6 months after diagnosis. No patient treated with tamoxifen developed EPS. Overall mortality was significantly higher in CG (71% vs. 22%, p = 0.03). Although follow-up was longer in CG, half the patients in that group died during the first 2 years after diagnosis. Our experience suggests that treatment with tamoxifen of patients diagnosed with peritoneal sclerosis diminishes the related complications and significantly reduces mortality, at least in the short- to mid-term. However, a prospective therapeutic trial is required to confirm our results.

Home training experience in peritoneal dialysis patients.

The objective of nursing is to increase health and well being, prevent morbidity and obtain the best physical and social rehabilitation. The nurse's role in Peritoneal Dialysis (PD) consists of promoting and supporting patients to perform self-care. In the'Text Book of Peritoneal Dialysis, published in 2000,the chapter dedicated to the nurses' role says:"Regular home visits are an important part of follow-up care, as the family and patient need to realize that continuing support is available... It is advisable that the first exchange after discharge from hospital is in the presence of a nurse... Early recognition and management of problems will assist in keeping the patient healthy and well rehabilitated, and will hopefully reduce hospital visits and inpatient stays" (1). Home care in Hospital Universitario La Paz has been developed with varying dedication over the years. Firstly, it was offered if significant problems appeared (1979-1990), later, home visits were started for some new PD patients (1990-1994) and follow up visits then ensued (1995-1996). In 1997, a project was undertaken which included home training for the first time in our unit, as well as periodic follow up visits. This project was shown to the Hospital Nurse Direction, and approved immediately. It started during the first term of 1997. There were several reasons which led us to undertake this project including the importance of providing PD at home and making it lifelong and it was felt that the hospital was an unfriendly environment in which to learn PD. The main objective was to establish early on, the patient's social environment and psychological status, and to assess how these influenced aspects of learning and adapting to PD. Most patients expressed a very good opinion about the home training. Only one patient rejected the presence of the nurse at home. The nursing team was very satisfied because early knowledge about the patient's psychosocial conditions and family environment was established. The incidence of peritonitis decreased.