Aniridia and the ocular surface: Medical and surgical problems and solutions.

Congenital aniridia is a multisystemic genetic disease due to a mutation in PAX6 gene which severely affects the development and functionality of the human eyes. In patients affected by the mutation, aside from the absence or defects of iris tissue formation, abnormalities in position or opacities of the crystalline lens, macular hypoplasia, ocular surface disease is the main cause of visual loss and the deterioration of the quality of life of most patients. Limbal stem cell deficiency combined with tear film instability and secondary dry eye cause aniridic keratopathy which, in advanced stages, ends up in corneal opacification. In this paper, the actual knowledge about congenital aniridia keratopathy physiopathology and medical and surgical treatment options and their efficacy are discussed. Indications and results of topical treatments with artificial tears and blood-derivatives in its initial stages, and different surgical techniques as limbal stem cell transplantation, keratoplasty and keratoprostheses are reviewed. Finally, recent advances and results in regenerative medicine techniques with ex vivo stem cell cultivation or other types of cultivated cells are presented.

¿Se han producido cambios en la aplicación de la ventilación mecánica en relación con la evidencia científica? Estudio multicéntrico en México / Have there been changes in the application of mechanical ventilation in relation to scientific evidence? A multicenter observational study in Mexico

OBJETIVO: Los objetivos principales son describir la práctica de la ventilación mecánica en un periodo de 18 años en México y estimar los cambios en la mortalidad de los pacientes críticos con ventilación mecánica invasiva (VMI). DISEÑO: Subanálisis retrospectivo de un estudio prospectivo y observacional en 1998, 2004, 2010 y 2016. ÁMBITO: Unidades de Cuidados Intensivos (UCI) de México. PARTICIPANTES: Pacientes adultos que ingresaron consecutivamente en la UCI, durante un mes y que recibieron VMI durante más de 12 h o ventilación mecánica no invasiva durante más de una hora. El seguimiento se realizó hasta 28 días después de la inclusión. INTERVENCIONES: Ninguna. VARIABLES DE INTERÉS: Edad, sexo, gravedad al ingreso estimada por el SAPS II, parámetros de la gasometría arterial diaria, variables de tratamiento y complicaciones, fecha y estado al alta de la UCI y del hospital. RESULTADOS: Se incluyó a 959 pacientes en 81 UCI. El volumen corriente (VC) ha disminuido significativamente tanto en pacientes con criterios de SDRA (de 8,5 ml/kg de peso estimado en 1998 a 6 ml/kg en 2016; p < 0,001) como en enfermos sin SDRA (de 9 ml/kg de peso estimado en 1998 a 6ml/kg en 2016; p < 0,001). La estrategia ventilatoria protectora (definida como VC < 6 ml/kg o < 8 ml/kg y una presión meseta < 30 cmH2O) fue: 19% en 1998, 44% en 2004, 58% en 2010 y 75% en 2016 (p < 0,001). La mortalidad ajustada en UCI a lo largo de los 4 periodos fue: en 2004, oportunidad relativa (OR) 1,05 (IC 95%: 0,73-1,72; p = 0,764); en 2010, OR 1,68 (IC 95%: 1,13-2,48; p = 0,009); en 2016, OR 0,85 (IC 95%: 0,60-1,20; p = 0,368). CONCLUSIONES: La práctica clínica de la VMI en las UCI de México se ha modificado a lo largo de un periodo de 18 años. El cambio más significativo es la estrategia ventilatoria basada en VC bajos. Estos cambios no se han asociado a cambios significativos en la mortalidad

OBJECTIVE: The main study objectives were to describe the practice of mechanical ventilation over an 18-year period in Mexico, and estimate changes in mortality among critical patients subjected to invasive mechanical ventilation (IMV). DESIGN: A retrospective subanalysis of a prospective observational study conducted in 1998, 2004, 2010 and 2016 was carried out. SETTING: Intensive Care Units (ICUs) in Mexico. PARTICIPANTS: Adult patients consecutively enrolled in the ICU during one month and who underwent IMV for more than 12hours or noninvasive mechanical ventilation for more than one hour. Follow-up was performed up to a maximum of 28 days after inclusion. INTERVENTIONS: None. PRINCIPAL VARIABLES OF INTEREST: Age, sex, severity upon admission as estimated by SAPS II, parameters of daily arterial blood gases, treatment and complication variables, date and status at discharge from the ICU and from hospital. RESULTS: A total of 959 patients were included in 81 ICUs. Tidal volume (vt) decreased significantly both in patients with acute respiratory distress syndrome (ARDS) criteria (estimated 8.5 ml/kg b.w. in 1998 to 6 ml/kg in 2016; P < 0.001) and in patients without ARDS (estimated 9 ml/kg b.w. in 1998 to 6 ml/kg in 2016; P < 0.001). The ventilatory protective strategy (defined as vt < 6 ml/kg or < 8 ml/kg and a plateau pressure < 30 cmH2O) was: 19% in 1998, 44% in 2004, 58% in 2010 and 75% in 2016 (P < 0.001). The adjusted mortality rate in ICU over the 4 periods was: in 2004, odds ratio (OR) 1.05 (95% confidence interval, 95% CI: 0.73-1.72; P = 0.764); in 2010, OR 1.68 (95% CI: 1.13-2.48; P = 0.009); in 2016, OR 0.85 (95%CI: 0.60-1.20; P = 0.368). CONCLUSIONS: The clinical practice of IMV in Mexican ICUs has been modified over a period of 18 years. The most significant change is the ventilatory strategy based on low vt. These changes have not been associated with significant changes in mortality

Have there been changes in the application of mechanical ventilation in relation to scientific evidence? A multicenter observational study in Mexico. / ¿Se han producido cambios en la aplicación de la ventilación mecánica en relación con la evidencia científica? Estudio multicéntrico en México.

OBJECTIVE: The main study objectives were to describe the practice of mechanical ventilation over an 18-year period in Mexico, and estimate changes in mortality among critical patients subjected to invasive mechanical ventilation (IMV). DESIGN: A retrospective subanalysis of a prospective observational study conducted in 1998, 2004, 2010 and 2016 was carried out. SETTING: Intensive Care Units (ICUs) in Mexico. PARTICIPANTS: Adult patients consecutively enrolled in the ICU during one month and who underwent IMV for more than 12hours or noninvasive mechanical ventilation for more than one hour. Follow-up was performed up to a maximum of 28 days after inclusion. INTERVENTIONS: None. PRINCIPAL VARIABLES OF INTEREST: Age, sex, severity upon admission as estimated by SAPS II, parameters of daily arterial blood gases, treatment and complication variables, date and status at discharge from the ICU and from hospital. RESULTS: A total of 959 patients were included in 81 ICUs. Tidal volume (vt) decreased significantly both in patients with acute respiratory distress syndrome (ARDS) criteria (estimated 8.5ml/kg b.w. in 1998 to 6ml/kg in 2016; P<0.001) and in patients without ARDS (estimated 9ml/kg b.w. in 1998 to 6ml/kg in 2016; P<0.001). The ventilatory protective strategy (defined as vt < 6ml/kg or < 8ml/kg and a plateau pressure < 30cmH2O) was: 19% in 1998, 44% in 2004, 58% in 2010 and 75% in 2016 (P<0.001). The adjusted mortality rate in ICU over the 4 periods was: in 2004, odds ratio (OR) 1.05 (95% confidence interval, 95%CI: 0.73-1.72; P=0.764); in 2010, OR 1.68 (95%CI: 1.13-2.48; P=0.009); in 2016, OR 0.85 (95%CI: 0.60-1.20; P=0.368). CONCLUSIONS: The clinical practice of IMV in Mexican ICUs has been modified over a period of 18 years. The most significant change is the ventilatory strategy based on low vt. These changes have not been associated with significant changes in mortality.

National survey on the indicators of quality in Bioethics of the SEMICYUC in the departments of Intensive Care Medicine in Spain. / Encuesta nacional sobre los indicadores de calidad en Bioética de la SEMICYUC, en los servicios de Medicina Intensiva en España.

INTRODUCTION: Multiple interventions are performed in critical patients admitted to Intensive Care Units (ICUs). This study explores the presence in the daily practice of ICUs of elements related to the 6 bioethics quality indicators of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units, and the participation of their members in the hospital ethics committees. MATERIALS AND METHODS: A multicenter observational study was carried out, using a survey exploring descriptive aspects of the ICUs, with 25 questions related to bioethics quality indicators, and assessing the participation of ICU members in the hospital ethics committees. The ICUs were classified by size (larger or smaller than 10 beds) and type of hospital (public/private-public concerted center, with/without teaching). RESULTS: The 68 analyzed surveys revealed: daily informing of the family (97%), carried out in the information room (82%); end-of-life care protocols (44%); life support limitation form (48.43%); and physical containment protocol (40%). Compliance with the informed consent process referred to different procedures is: tracheostomy (92%), vascular procedures (76%), and extrarenal clearance (25%). The presence of ICU members in the hospital ethics committee is currently frequent (69%). CONCLUSIONS: Information supplied to relatives is adequate, although there are ICUs without an information room. Compliance with the informed consent requirements of various procedures is insufficient. The participation of ICU members in the hospital ethics committees is frequent. The results obtained suggest a chance for improvement in the bioethical quality of the ICU.

Autologous Haematopoietic Stem Cell Transplantation for Refractory Crohn's Disease: Efficacy in a Single-Centre Cohort.

BACKGROUND: Haematopoietic stem cell transplantation [HSCT] is considered a therapeutic option for patients with severe Crohn's disease [CD] unresponsive to currently available therapies. METHODS: Autologous HSCT was considered for CD patients with active disease, unresponsive or intolerant to approved medications and unsuitable for surgery. After HSCT, patients were closely followed up every 6 weeks during the first 2 years and every 6 months thereafter up to 5 years. Colonoscopy and/or magnetic resonance imaging were performed at Months 6, 12, 24, and 48 after HSCT. RESULTS: From December 1, 2007 to December 31, 2015, 37 CD patients were assessed for HSCT. Of these, 35 patients [13 within the ASTIC trial] underwent mobilisation. Six patients did not complete the transplant for various reasons and 29 patients were finally transplanted. Patients were followed up during a median of 12 months [6-60]. At 6 months, 70% of patients achieved drug-free clinical remission (Crohn's Disease Index of Severity [CDAI] < 150). The proportion of patients in drug-free remission (CDAI < 150, Simple Endoscopic activity Score [SES]-CD < 7] was 61% at 1 year, 52% at 2 years, 47% at 3 years, 39% at 4 years, and 15% at 5 years. Patients who relapsed were re-treated and 80% regained clinical remission. Six out of the 29 [21%] required surgery. One patient died due to systemic cytomegalovirus infection 2 months after transplant. CONCLUSIONS: HSCT is a salvage therapy for patients with extensive and refractory CD. Although relapse occurs in a majority of patients within 5 years after transplant, drug responsiveness is regained and clinical remission achieved in 80% of cases.

IV Conferencia Española de Consenso sobre el tratamiento de la infección por Helicobacter pylor / IV Spanish Consensus Conference on Helicobacter pyloriinfection treatment

La infección por Helicobacter pylori afecta aproximadamente al 50% de la población española y es causante de la gastritis crónica, la úlcera péptica y el cáncer gástrico. Se han llevado a cabo hasta el momento, en nuestro país, 3 reuniones de Consenso sobre el manejo de la infección por H. pylori (la última de ellas en 2012). Los cambios en los esquemas de tratamiento y la creciente evidencia disponible al respecto han justificado la organización de esta IV Conferencia Española de Consenso en marzo de 2016, centrada en el tratamiento de esta infección. Participaron 19 expertos sobre el tema, que realizaron una búsqueda sistemática de la evidencia científica y elaboraron una serie de recomendaciones que fueron sometidas a un proceso de interacción de votaciones anónimas seriadas mediante metodología Delphi. Para clasificar la evidencia científica y la fuerza de las recomendaciones se utilizó el sistema GRADE. Este consenso establece, como punto de partida, un aumento de la exigencia en la eficacia de los tratamientos recomendados, que deben alcanzar, o preferiblemente superar, el 90% de curación al ser administrados de forma empírica. De este modo, tanto en primera como en segunda línea se recomiendan tratamientos cuádruples con o sin bismuto, generalmente prescritos durante 14días. El tratamiento cuádruple sin bismuto concomitante, que incluye un inhibidor de la bomba de protones, claritromicina, amoxicilina y metronidazol, se recomienda como primera línea. En el presente consenso se revisan también con detalle otras alternativas de tratamiento tanto de primera línea como de rescate

Helicobacter pylori approximately infect 50% of Spanish population and causes chronic gastritis, peptic ulcer and gastric cancer. Until now, three consensus meetings on H. pyloriinfection had been performed in Spain (the last in 2012). The changes in the treatment schemes, and the increasing available evidence, have justified organizing the IV Spanish Consensus Conference (March 2016), focused on the treatment of this infection. Nineteen experts participated, who performed a systematic review of the scientific evidence and developed a series of recommendation that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. As starting point, this consensus increased the minimum acceptable efficacy of recommended treatments that should reach, or preferably surpass, the 90% cure rate when prescribed empirically. Therefore, only quadruple therapies (with or without bismuth), and generally lasting 14 days, are recommended both for first and second line treatments. Non-bismuth quadruple concomitant regimen, including a proton pump inhibitor, clarithromycin, amoxicillin and metronidazole, is recommended as first line. In the present consensus, other first line alternatives and rescue treatments are also reviewed and recommended

IV Spanish Consensus Conference on Helicobacter pylori infection treatment. / IV Conferencia Española de Consenso sobre el tratamiento de la infección por Helicobacter pylori.

Helicobacter pylori approximately infect 50% of Spanish population and causes chronic gastritis, peptic ulcer and gastric cancer. Until now, three consensus meetings on H.pylori infection had been performed in Spain (the last in 2012). The changes in the treatment schemes, and the increasing available evidence, have justified organizing the IVSpanish Consensus Conference (March 2016), focused on the treatment of this infection. Nineteen experts participated, who performed a systematic review of the scientific evidence and developed a series of recommendation that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. As starting point, this consensus increased the minimum acceptable efficacy of recommended treatments that should reach, or preferably surpass, the 90% cure rate when prescribed empirically. Therefore, only quadruple therapies (with or without bismuth), and generally lasting 14 days, are recommended both for first and second line treatments. Non-bismuth quadruple concomitant regimen, including a proton pump inhibitor, clarithromycin, amoxicillin and metronidazole, is recommended as first line. In the present consensus, other first line alternatives and rescue treatments are also reviewed and recommended.

Improving safety of autologous haematopoietic stem cell transplantation in patients with Crohn's disease.

OBJECTIVE: To evaluate the feasibility and toxicity of autologous haematopoietic stem cell transplantation (HSCT) for the treatment of refractory Crohn's disease (CD). DESIGN: In this prospective study, patients with refractory CD suffering an aggressive disease course despite medical treatment, impaired quality of life and in whom surgery was not an acceptable option underwent HSCT. Toxicity and complications during the procedure and within the first year following transplantation were evaluated, along with the impact of the introduction of supportive measures on safety outcomes. RESULTS: 26 patients were enrolled. During mobilisation, 16 patients (62%) presented febrile neutropaenia, including one bacteraemia and two septic shocks. Neutropaenia median time after mobilisation was 5 days. 5 patients withdrew from the study after mobilisation and 21 patients entered the conditioning phase. Haematopoietic recovery median time for neutrophils (>0.5×10(9)/L) was 11 days and for platelets (>20×10(9)/L) 4 days. Twenty patients (95%) suffered febrile neutropaenia and three patients (27%) presented worsening of the perianal CD activity during conditioning. Among non-infectious complications, 6 patients (28.5%) presented antithymocyte globulin reaction, 12 patients (57%) developed mucositis and 2 patients (9.5%) had haemorrhagic complications. Changes in supportive measures over the study, particularly antibiotic prophylaxis regimes during mobilisation and conditioning, markedly diminished the incidence of severe complications. During the first 12-month follow-up, viral infections were the most commonly observed complications, and one patient died due to systemic cytomegalovirus infection. CONCLUSIONS: Autologous HSCT for patients with refractory CD is feasible, but extraordinary supportive measures need to be implemented. We suggest that this procedure should only be performed in highly experienced centres.

Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy.

OBJECTIVE: Achalasia is a chronic motility disorder of the oesophagus for which laparoscopic Heller myotomy (LHM) and endoscopic pneumodilation (PD) are the most commonly used treatments. However, prospective data comparing their long-term efficacy is lacking. DESIGN: 201 newly diagnosed patients with achalasia were randomly assigned to PD (n=96) or LHM (n=105). Before randomisation, symptoms were assessed using the Eckardt score, functional test were performed and quality of life was assessed. The primary outcome was therapeutic success (presence of Eckardt score ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for re-treatment, lower oesophageal sphincter pressure, oesophageal emptying and the rate of complications. RESULTS: In the full analysis set, there was no significant difference in success rate between the two treatments with 84% and 82% success after 5 years for LHM and PD, respectively (p=0.92, log-rank test). Similar results were obtained in the per-protocol analysis (5-year success rates: 82% for LHM vs. 91% for PD, p=0.08, log-rank test). After 5 years, no differences in secondary outcome parameter were observed. Redilation was performed in 24 (25%) of PD patients. Five oesophageal perforations occurred during PD (5%) while 12 mucosal tears (11%) occurred during LHM. CONCLUSIONS: After at least 5 years of follow-up, PD and LHM have a comparable success rate with no differences in oesophageal function and emptying. However, 25% of PD patients require redilation during follow-up. Based on these data, we conclude that either treatment can be proposed as initial treatment for achalasia. TRIAL REGISTRATION NUMBERS: Netherlands trial register (NTR37) and Current Controlled Trials registry (ISRCTN56304564).

Intensive care practices in brain death diagnosis and organ donation.

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Síndrome de Stickler. Epidemiología del desprendimiento de la retina / Stickler syndrome. Epidemiology of retinal detachment

OBJETIVO: Revisión de todos los pacientes con síndrome de Stickler que se han tratado en nuestro centro desde su descripción, para valorar el riesgo de padecer desprendimiento de la retina (DR). MÉTODOS: Un total de 14 pacientes, diagnosticados por criterios clínicos, en los que hemos valorado las siguientes variables: sexo, edad, antecedentes oculares, seguimiento, agudeza visual (AV) inicial y final, refracción, tratamiento profiláctico, cirugías y la técnica empleada. Mediante el análisis de curva de supervivencia de Kaplan-Meier hemos determinado la edad riesgo de padecer DR así como cataratas. RESULTADOS: En total fueron 5 hombres y 9 mujeres. La AV mediana inicial fue de 0,35, igual que la AV final. Refracción mediana de −9,5 dioptrías de miopía. La mediana de seguimiento de 7 años. Los antecedentes oculares fueron 4 DR y 2 Lasik. Las cirugías que realizamos han sido 8 DR, 12 cataratas, 2 glaucomas, 2 agujeros maculares y una endotropía. La mediana de años en el que sucedió el DR fue de 20 y las cataratas a los 34. La técnica quirúrgica utilizada en 4 casos ha sido el cerclaje y en los otros 4 restantes cerclaje con vitrectomía vía pars plana. Un total de 6 ojos han sido tratados profilácticamente: uno con cerclaje, 4 con fotocoagulación láser y otro con criocoagulación; de estos, 2 han presentado DR. CONCLUSIONES: En nuestra serie, el DR en esta dolencia se desarrolla mayoritariamente en la segunda década de la vida. Las cataratas, fundamentalmente en la cuarta década

OBJECTIVE: A review was performed on all patients with Stickler syndrome that had been treated in our Centre since it was diagnosed, in order to evaluate the risk of suffering a retinal detachment (RD). METHODS: A total of 14 patients, diagnosed by clinical criteria, were included. The following variables were evaluated: age, gender, ocular background, follow-up, initial and final visual acuity (VA), optical prescription, prophylactic treatment, surgery and techniques performed. The risk age to suffer a RD, as well as cataracts, was determined by using the Kaplan-Meier survival curve analysis. RESULTS: From a total of 5 men and 9 women, the median initial VA was 0.35, which was the same as the final VA. The median optical prescription was -9.5 D myopia. The median of follow-up was 7 years. Ocular background was 4 RD cases and 2 Lasik surgeries. The operations performed were 8 RD, 12 cataract, 2 glaucoma, 2 macular hole, and one endotropia. The median age of RD was 20 years and cataract 34 years. As regards surgical tecnique, 4 scleral buckle cases, and 4 scleral buckle + pars plana vitrectomy cases were formed. The prophylactic treatments performed were: one scleral buckle case, 4 endolaser photocoagulation, and one cryotherapy. Two of which presented with RD. CONCLUSION: In the series presented, retinal detachment in Stickler syndrome mainly occurs in the second decade of life, with cataracts mainly developing in the fourth decade

Microscale electrodes integrated on COP for real sample Campylobacter spp. detection.

Campylobacter spp. are responsible for acute bacterial diseases in human worldwide. Nowadays campilobacteriosis is considered the most common foodborne illness in the European Union. In this paper the first electrochemical genosensor based on thin-film gold electrodes deposited onto Cyclo Olefin Polymer (COP) substrates was fabricated for the detection of Campylobacter spp in food matrices. The sensing element is characterized by several surface techniques and the sensitivity of the biosensor have been studied. A good linear relationship was obtained for the concentrations of PCR amplicon of Campylobacter spp. between 1 and 25 nM with a limit of detection (LOD) of 90 pM. Real samples have been validated with poultry meat samples and results were comparable with the PCR product samples. This is the last step for the fabrication of a Lab on a Chip (LOC), a biodevice integrating DNA sensor technology into microfluidic system, believed to perform an automated and complete assay, including sample preparation, PCR amplification, and electrochemical detection of Campylobacter spp. in raw poultry meat samples.

Stickler syndrome. Epidemiology of retinal detachment.

OBJECTIVE: A review was performed on all patients with Stickler syndrome that had been treated in our Centre since it was diagnosed, in order to evaluate the risk of suffering a retinal detachment (RD). METHODS: A total of 14 patients, diagnosed by clinical criteria, were included. The following variables were evaluated: age, gender, ocular background, follow-up, initial and final visual acuity (VA), optical prescription, prophylactic treatment, surgery and techniques performed. The risk age to suffer a RD, as well as cataracts, was determined by using the Kaplan-Meier survival curve analysis. RESULTS: From a total of 5 men and 9 women, the median initial VA was 0.35, which was the same as the final VA. The median optical prescription was -9.5 D myopia. The median of follow-up was 7 years. Ocular background was 4 RD cases and 2 Lasik surgeries. The operations performed were 8 RD, 12 cataract, 2 glaucoma, 2 macular hole, and one endotropia. The median age of RD was 20 years and cataract 34 years. As regards surgical tecnique, 4 scleral buckle cases, and 4 scleral buckle+pars plana vitrectomy cases were formed. The prophylactic treatments performed were: one scleral buckle case, 4 endolaser photocoagulation, and one cryotherapy. Two of which presented with RD. CONCLUSION: In the series presented, retinal detachment in Stickler syndrome mainly occurs in the second decade of life, with cataracts mainly developing in the fourth decade.

Classifications of vitreomacular traction syndrome: diameter vs morphology.

PURPOSE: The aim of this study is to analyze the agreement between the classifications based on morphology and diameter of vitreomacular traction (VMT) syndrome, as well as to correlate the morphological findings of VMT with specific maculopathies. METHODS: Fifty-three eyes with VMT syndrome were categorized into two classifications based on optical coherence tomography images: the VMT morphology (V- or J-shaped) and the diameter of adhesion (focal ≤ 1500 µm or broad>1500 µm). RESULTS: High correlation was seen between V-shaped and focal-VMT and between J-shaped and broad-VMT (kappa=0.850; P<0.001), except in four cases with broad adhesion despite the presence of a V-shaped pattern. These four cases had common characteristics to those with broad vitreal attachment regarding associated maculopathies and visual function. V-shaped VMT (n=29) and focal-VMT (n=25) led to tractional cystoid macular edema (CME; 79.31% and 84%, respectively) and macular hole (MH; 37.93% and 44%); J-shaped VMT (n=24) and broad-VMT (n=28) were associated with epiretinal membranes (ERMs; 91.66% and 92.85%, respectively) and diffuse retinal thickening (62.50% and 64.28%). The best-corrected visual acuity (BCVA) was not significantly different between the groups (BCVA logarithm of the minimum angle of resolution: V-shaped, 0.45; J-shaped, 0.46; P=0.816; and focal, 0.50; broad, 0.42; P=0.198). CONCLUSIONS: Although highly concordant, the classification based on the diameter of the adhesion and not on the classical adhesion morphology seemed to better reflect the specific macular changes. V-shaped and focal VMT led to tractional CME and MH, while J-shaped and broad VMT were associated with ERM and diffuse retinal thickening.

Complicación tras acceso vascular para hemodiálisis. Aneurisma de la arteria humeral / Complications after vascular access for hemodialysis: humeral artery aneurysm

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Outcomes of treatment for achalasia depend on manometric subtype.

BACKGROUND & AIMS: Patients with achalasia are treated with either pneumatic dilation (PD) or laparoscopic Heller myotomy (LHM), which have comparable rates of success. We evaluated whether manometric subtype was associated with response to treatment in a large population of patients treated with either PD or LHM (the European achalasia trial). METHODS: Esophageal pretreatment manometry data were collected from 176 patients who participated in the European achalasia trial. Symptoms (weight loss, dysphagia, retrosternal pain, and regurgitation) were assessed using the Eckardt score; treatment was considered successful if the Eckardt score was 3 or less. Manometric tracings were classified according to the 3 Chicago subtypes. RESULTS: Forty-four patients had achalasia type I (25%), 114 patients had achalasia type II (65%), and 18 patients had achalasia type III (10%). After a minimum follow-up period of 2 years, success rates were significantly higher among patients with type II achalasia (96%) than type I achalasia (81%; P < .01, log-rank test) or type III achalasia (66%; P < .001, log-rank test). The success rate of PD was significantly higher than that of LHM for patients with type II achalasia (100% vs 93%; P < .05), but LHM had a higher success rate than PD for patients with type III achalasia (86% vs 40%; P = .12, difference was not statistically significant because of the small number of patients). For type I achalasia, LHM and PD had similar rates of success (81% vs 85%; P = .84). CONCLUSIONS: A higher percentage of patients with type II achalasia (based on manometric tracings) are treated successfully with PD or LHM than patients with types I and III achalasia. Success rates in type II are high for both treatment groups but significantly higher in the PD group. Patients with type III can probably best be treated by LHM. Trialregister.nl number NTR37; ISRCTN56304564.

Continuously evaluating performance in deceased donation: the Spanish quality assurance program.

The Spanish Quality Assurance Program applied to the process of donation after brain death entails an internal stage consisting of a continuous clinical chart review of deaths in critical care units (CCUs) performed by transplant coordinators and periodical external audits to selected centers. This paper describes the methodology and provides the most relevant results of this program, with information analyzed from 206,345 CCU deaths. According to the internal audit, 2.3% of hospital deaths and 12.4% of CCU deaths in Spain yield potential donors (clinical criteria consistent with brain death). Out of the potential donors, 54.6% become actual donors, 26% are lost due to medical unsuitability, 13.3% due to refusals to donation, 3.1% due to maintenance problems and 3% due to other reasons. Although the national pool of potential donors after brain death has progressively decreased from 65.2 per million population (pmp) in 2001 to 49 pmp in 2010, the number of actual donors after brain death has remained at about 30 pmp. External audits reveal that the number of actual donors could be 21.6% higher if all potential donors were identified and preventable losses avoided. We encourage other countries to develop similar comprehensive approaches to deceased donation performance.

Embolización en paralelo o en caños de escopeta / Embolisation in parallel or double-barrel

La comercialización de dispositivos mallados de nitinol análogos a los stents, con la finalidad de trombosar un vaso (Amplatzer Plugs), ha supuesto un importante avance en la técnica de embolización endovascular; sin embargo en arterias con calibres superiores a 22 mm de diámetro nos encontramos sin las prótesis adecuadas. Presentamos una técnica alternativa a la utilización de numerosos coils(AU)

The marketing of nitinol meshing devices, which are similar to stents, with the purpose of thrombosing a blood vessel (Amplatzer Vascular Plugs) has lead to an important advance in endovascular embolisation technique. However, the appropriate grafts have not been found for arteries with calibres greater than 22 mm. In this article, we present a good alternative to the use of multiple coils(AU)

Utilidad de la biopsia endoscópica en el esófago de Barrett / Usefulness of endoscopic biopsy in Barrett's esophagus

Fundamento y objetivo: La endoscopia con obtención de biopsias múltiples es la técnica estándar para el diagnóstico y seguimiento del esófago de Barrett (EB). El objetivo de este trabajo fue estudiar la utilidad de las biopsias endoscópicas en el diagnóstico y seguimiento de los pacientes con EB. Pacientes y método: Estudio retrospectivo de todos los pacientes con EB controlados en el Hospital Clínic desde febrero de 2002 hasta marzo de 2010. Resultados: En el período de estudio se realizaron 493 endoscopias a 206 pacientes. Se excluyeron 86 pacientes a los que se les había realizado solo una endoscopia, siendo la muestra final de 117 pacientes (edad media [DE] de 61 [12] años y 73% de varones) con 407 endoscopias y un tiempo medio de seguimiento de 45 (38) meses. Un total de 57 pacientes tenían un EB corto (49%), 28 un EB largo (24%) y en 32 (27%) no se pudo deducir del informe. En 25 casos (21%) no se detectó metaplasia intestinal (MI) en la endoscopia inicial. Durante el seguimiento, las biopsias fueron negativas para MI en algún momento en 45 pacientes (38,4%) y se produjo un cambio en el grado histológico en 100 ocasiones (24,6%). La presencia de un EB corto (43% en EB corto frente a 7% en EB largo; p=0,001) y un menor número de biopsias (media de 3 [1,5] frente a 6,2 [4,5], p=0,005) se asociaron a una mayor frecuencia de biopsias negativas para MI. Conclusión: Las biopsias endoscópicas múltiples no son una buena herramienta para el diagnóstico y seguimiento de los pacientes con EB (AU)

Background and objetive: Endoscopy with random biopsies is the standard technique for the diagnosis of Barrett's esophagus (BE). We studied the usefulness of endoscopic biopsies in the diagnosis and surveillance of patients with BE.Patients: We reviewed all patients with BE controlled at the Hospital Clínic from February 2002 to March 2010. Results: During the study period, 493 endoscopies were performed in 206 patients. We excluded 86 patients who had undergone one endoscopy only, hence the final sample consisted of 117 patients (mean age 61 [12] years, 73% men) with 407 endoscopies and a mean follow-up of 45 (38) months. Fifty-seven patients had a short-BE (49%), 28 a long-BE (24%) and 32 (27%) could not be inferred from the report. In 25 cases (21%), intestinal metaplasia (IM) was not detected at the endoscopic index. During follow-up, biopsies were negative for IM at some point in 45 patients (38.4%) and there was a change in the histologic grade in 100 cases (24.6%). The presence of a short-BE (43% in short-BE vs 7% in long-BE, P=.001) and few biopsies (3 [1.5] vs 6.2 [4.5]; P=.005) were associated with a higher frequency of negative biopsies for IM. Conclusion: Random endoscopic biopsies are not a good tool for diagnosis and surveillance of patients with BE (AU)