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.

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

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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)

[Acute necrotizing esophagitis in an unstable patient]. / Esofagitis necrotizante aguda en paciente inestable.

Acute necrotizing esophagitis or black esophagus is a rare affection, described in the medical literature since 1990. Although its mechanism is not fully understood, ischemic compromise appears to be the fundamental physiopathological factor. When acute necrotizing esophagitis is found in the endoscopic study of an upper digestive haemorrhage, the prognosis is good. We present a case in which diagnosis of black esophagus was an endoscopic finding, secondary to a situation of underlying hemodynamic instability, with a fatal outcome.

Esofagitis necrotizante aguda en paciente inestable / Acute necrotizing esophagitis in an unstable patient

La esofagitis necrotizante aguda o esófago negroes una afección rara, conocida en la literatura médicadesde 1990. Aunque su mecanismo no es del todo conocido,el compromiso isquémico parece ser el factorfisiopatológico fundamental. Cuando la esofagitis necrotizanteaguda es un hallazgo en el estudio endoscópicode hemorragia digestiva alta, sin desestabilizaciónhemodinámica, el pronóstico es bueno. Presentamosun caso en el que el diagnóstico de esófago negro fue unmero hallazgo endoscópico, secundario a una situaciónde inestabilidad hemodinámica subyacente, con resultadofatal(AU)

Acute necrotizing esophagitis or black esophagusis a rare affection, described in the medical literaturesince 1990. Although its mechanism is not fully understood,ischemic compromise appears to be thefundamental physiopathological factor. When acutenecrotizing esophagitis is found in the endoscopic studyof an upper digestive haemorrhage, the prognosisis good. We present a case in which diagnosis of blackesophagus was an endoscopic finding, secondary to asituation of underlying hemodynamic instability, with afatal outcome(AU)

Tratamiento endovascular de pseudoaneurisma subclavio iatrogénico. A propósito de un caso / Endovascular treatment of iatrogenic subclavian pseudoaneurysms. A case report

Introducción. La cateterización de vías venosas centrales puede presentar como rara complicación la formación de un pseudoaneurisma en una arteria adyacente por punción inadvertida de ésta. Caso clínico. Mujer de 45 años que, tras ser intervenida de cirugía bariátrica, presentó complicaciones que requirieron reingreso en el hospital y estancia en la Unidad de Cuidados Intensivos, necesitándose una vía central subclavia izquierda para su tratamiento. Tras el alta, la paciente refirió la aparición de masa pulsátil súbita en la región laterocervical izquierda que resultó un pseudoaneurisma subclavio, tratado con éxito mediante implante endovascular de stent recubierto vía femoral derecha. Conclusiones. En la arteria subclavia, el tratamiento quirúrgico sigue siendo complejo, particularmente si es necesario abordar el tórax o en pacientes de alto riesgo. En los últimos años, el uso de técnicas endovasculares en las lesiones de la arteria subclavia, tanto traumáticas como iatrogénicas, han minimizado las complicaciones del tratamiento quirúrgico

Introduction. A rarely observed complication deriving from catheterisation of central venous lines is the formation of a pseudoaneurysm in an adjacent artery owing to accidental puncture. Case report. Here we report the case of a 45-year-old female who, following bariatric surgery, developed as series of complications that required readmission to hospital and a stay in the Intensive Care Unit; treatment was established with a left-side subclavian central line. After being discharged from hospital, the patient reported the sudden appearance of a pulsatile mass on the left side of the neck, which turned out to be a subclavian pseudoaneurysm and was successfully treated by implanting a covered stent via the right femoral. Conclusions. Surgical treatment is still complex in the subclavian artery, and more so if it is necessary to approach the thorax or in high-risk patients. In recent years, the use of endovascular techniques to treat both traumatic and iatrogenic lesions in the subclavian artery have minimised the complications deriving from surgical treatment

[Use of internet and electronic resources among Spanish intensivist physicians. First national survey]. / Uso de Internet y recursos electrónicos entre médicos intensivistas españoles. Primera encuesta nacional.

OBJECTIVE: Estimate knowledge and use habits of different electronic resources in a sample of Spanish intensivists: Internet, E-mail, distribution lists, and use of portable electronic devices. DESIGN: Self-applied questionnaire. METHODS: A 50-question questionnaire was distributed among Spanish intensivists through the hospital marketing delegates of a pharmaceutical company and of electronic forums. RESULTS: A total of 682 questionnaires were analyzed (participation: 74%). Ninety six percent of those surveyed used Internet individually: 67% admitted training gap. Internet was the second source of clinical consultations most used (61%), slightly behind consultation to colleagues (65%). The pages consulted most were bibliographic databases (65%) and electronic professional journals (63%), with limited use of Evidence Based Medicine pages (19%). Ninety percent of those surveyed used e-mail regularly in the practice of their profession, although 25% admitted that were not aware of its possibilities. The use of E-mail decreased significantly with increase in age. A total of 62% of the intensivists used distribution lists. Of the rest, 42% were not aware of its existence and 32% admitted they had insufficient training to handle them. Twenty percent of those surveyed had portable electronic devices and 64% considered it useful, basically due to its rapid consultation at bedside. Female gender was a negative predictive factor of its use (OR 0.35; 95% CI 0.2-0.63; p=0.0002). CONCLUSIONS: A large majority of the Spanish intensivists use Internet and E-mail. E-mail lists and use of portable devices are still underused resources. There are important gaps in training and infrequent use of essential pages. There are specific groups that require directed educational policies.

Tratamiento endovascular de aneurisma en aloinjerto femoropoplíteo. A propósito de un caso / Endovascular treatment of an aneurysm in a femoral-popliteal allograft. A case report

Introducción. La aparición de aneurismas en los injertos vasculares de vena umbilical humana se describió por primera vez en 1982. El tratamiento más habitual ha sido la cirugía. La llegada de las técnicas endovasculares ha incrementado las posibilidades terapéuticas que podemos ofrecer al paciente así como ha minimizado las complicaciones de la cirugía. Caso clínico. Paciente de 76 años con isquemia crónica de extremidades inferiores, intervenido en varias ocasiones (simpatectomía lumbar izquierda, bypass femoropoplíteo izquierdo a primera porción con politetrafluoroetileno en 1989 y bypass femoropoplíteo izquierdo a tercera porción con bioprótesis homóloga en 1994). Durante el seguimiento apareció dilatación aneurismática en aloinjerto diagnosticado mediante eco-Doppler. Se completó el estudio con tomografía axial computarizada (TAC) y angiografía por resonancia magnética. Como tratamiento, se implantó stent recubierto Viabahn de 8 × 100 mm, quedando el aneurisma completamente excluido. A los seis meses de seguimiento no se aprecian endofugas ni migración, y permanece permeable según eco-Doppler y TAC. Conclusión. El avance en las técnicas endovasculares permite un tratamiento rápido y sencillo de los aneurismas de injertos infrainguinales, especialmente útil en pacientes técnicamente complicados o de alto riesgo quirúrgico

INTRODUCTION. The appearance of aneurysms in human umbilical vein vascular grafts was first reported in 1982. Surgical intervention has been the most common treatment until now. The advent of endovascular techniques has expanded the possible therapeutic options that we can offer the patient, while at the same minimising the complications that can result from the intervention. CASE REPORT. We report the case of a 76-year-old patient with chronic ischaemia in both lower extremities who had been submitted to surgery on several occasions (left-side lumbar sympathectomy, a femoral-popliteal polytetrafluoroethylene bypass in the first portion of the left-hand side in 1989 and a femoral-popliteal bypass in the third portion with a homologous bioprosthesis in 1994). During the follow-up an aneurysmal dilatation appeared in the allograft, as diagnosed by Doppler ultrasound recording. The study was completed with computerised axial tomography (CAT) and magnetic resonance angiography. Treatment consisted in the placement of an 8 × 100 mm Viabahn covered stent, after which the aneurysm was completely excluded. At three months’ follow-up no endoleaks or migration were detected and, according to Doppler ultrasound and a CAT scan, patency is preserved. CONCLUSION. The progress being made in endovascular techniques allows fast, simple treatment of aneurysms in infrainguinal grafts, which is especially useful in technically complicated patients or those with a high surgical risk

Isquemia aguda por embolia paradójica / Acute ischemia due to paradoxical embolism

Introducción. La embolia paradójica es un raro evento dentro de los fenómenos isquémicos centrales o periféricos que necesariamente requieren un proceso trombótico venoso o cardíaco más una comunicación derecha-izquierda, habitualmente cardíaca. El correcto diagnóstico y tratamiento es fundamental en el manejo de esta inusual patología para prevenir recurrencias posteriores. Caso clínico. Mujer de 35 años con antecedentes de obesidad mórbida y encamamiento continuado de cuatro días, que acudió por presentar un cuadro isquémico agudo de la extremidad superior izquierda con pérdida de todos los pulsos a ese nivel acompañado de disnea, hipoxemia e hipocapnia. Se realizó una arteriografía urgente que evidenció el cuadro isquémico agudo sobre la arteria subclavia, de probable origen embólico, y ante la sospecha de embolismo pulmonar concomitante se realizó igualmente una angiografía pulmonar que confirmó un tromboembolismo pulmonar masivo, y se intuyó al mismo tiempo una comunicación derecha izquierda por el llenado simultáneo de arteria pulmonar y aorta; se sospechó, por tanto, de la existencia de un embolismo paradójico. La embolectomía se realizó sin incidencias, y el embolismo pulmonar se trató mediante fragmentación local más perfusión de uroquinasa durante 24 horas con estancia perioperatoria en unidad de cuidados intensivos más implante de filtro de cava temporal. Controlada la situación clínica de la paciente, se continuó el estudio con el diagnóstico posterior de foramen oval permeable mediante ecografía transesofágica que se cerró mediante abordaje percutáneo femoral e implante de oclusor tipo Amplatzer (PFO). Se dio de alta a la paciente tras completar el paso a anticoagulación oral ya que en todo momento estuvo bajo tratamiento con heparina sódica en perfusión. Conclusiones. La embolia paradójica supone un mínimo porcentaje de todos los casos de isquemias agudas. No obstante, se debe sospechar de su existencia ante casos atípicos de episodios isquémicos, asociados o no a clínica de trombosis venosa profunda, y valorarse siempre de manera individualizada dada la falta de estrategia definida ante esta inusual patología (AU)

Tratamiento y pronóstico de la reagudización grave en la enfermedad pulmonar obstructiva crónica / Treatment and prognosis of the severe exarcebation in the chronic obstructive pulmonary didease

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Reagudización en la EPOC con oxigenoterapia domiciliaria. UCI y ventilación mecánica. ¿Tenemos respuestas? / Aggravation of EPOC with domiciliary oxygen therapy. The intensive care unit and mechanical ventilation. Do we have answers?

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Tratamiento con surfactante en el síndrome de distrés respiratorio agudo. ¿Todo dicho? / Surfactant therapy in the acute respiratory distress syndrome. Has been said everything?

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[Acute respiratory distress syndrome. Nutritional and metabolic support]. / Síndrome de distrés respiratorio agudo. Soporte nutro-metabólico.

The application of artificial nutritional treatment in critical patients, nowadays is a completely accepted fact. To a large degree this is due to the advances made in the understanding of the metabolic response shown by patients against a severe and persistent aggression. One of the entities which presents the highest mortality in critical patients, is the Acute Respiratory Distress Syndrome (ARDS), which one understands as the pulmonary response to different types of aggression. To understand the metabolic implications in the face of the development of this syndrome, would permit a better understanding of the need to treat these patients and to establish the nutritional standards which are most adequate to each different metabolic alteration. It would not only be important to understand the most effective method for calculating the caloric needs of these patients, but we shall also have to deepen our understanding of possible harmful effects of the different substrates, which undoubtedly could condition morbidity. This is why in this review we focus on the intimate pulmonary mechanism, both in healthy conditions as in those of disease, in order to extrapolate conclusions which are potentially applicable to patients suffering from an acute pulmonary lesion, as those suffering from ARDS: A main role shall be played the assessment of the administration of macronutrients in the form carbohydrates, lipids, and amino acid particles, due to the implications which each of these may have on the lesioned lung and its ventilatory capacity.

Gliosarcoma. Case report with immunohistochemical study.

A typical case of gliosarcoma in a 74 year-old woman is reported. The exact origin of sarcomatous areas of this tumor has been a matter of debate. Our immunohistochemical findings, using a panel of antibodies (GFAP), vimentin, keratins, F-VIII related antigen, muscle specific actin, KP-1 and HMB-45), support its undifferentiated nature. The literature concerning this topic is reviewed and briefly discussed.

A case of Whipple's disease presenting as supraclavicular lymphadenopathy. A case report.

A case of Whipple's disease occurring in a 63-year-old woman is reported. Cervical lymphadenopathy and vague constitutional symptoms were soon followed by diarrhea and weight loss. Supraclavicular lymph node exeresis suggested the initial diagnosis, which was confirmed by intestinal biopsy. The concurrence of cystic spaces, PAS-positive foamy histiocytes and epithelioid granulomas is considered by the authors to provide a useful histological clue in the diagnosis of lymph node involvement in Whipple's disease. Pathologists must be aware of such an un-conventional presentation of this rare entity and therefore include it within the differential diagnosis of cervical and/or axillary lymphadenopathies.

Extraskeletal myxoid chondrosarcoma. A clinicopathologic and immunohistochemical study of two cases.

Two extraskeletal myxoid chondrosarcomas arising on the left lower extremity of two women, aged 48 and 72 years, respectively, are reported. One case mimicked clinically an organized hematoma. By light microscopy, they showed a lobular architecture. Anastomosing cords of cells lying in a myxoid background were the histologic hallmark. Based on conventional criteria, they were classified as neoplasms of low (G1) and intermediate (G2) grade malignancy. Both cases were strongly positive for S-100 protein and vimentin. Follow-up confirmed the low aggressiveness of this entity.

Frozen section diagnosis in a jugulo-tympanic paraganglioma.

The light microscopy and immunohistochemical findings of a jugulo-tympanic paraganglioma occurring in a 29-year-old man are reported. Diagnostic difficulties from frozen sections are stressed and selected literature is briefly commented upon.

Central mucoepidermoid carcinoma. Report of a case and review of the literature.

A case of central mucoepidermoid carcinoma (CMEC) occurring in a 68-year-old woman is reported. The tumor clinically appeared as a long-standing cortical swelling in the left angle of her mandible. As an intrabony lesion was radiologically evidenced, an odontogenic cyst was preoperatively diagnosed. Surgical curettage demonstrated a solid tumor the histological study of which allowed the final diagnosis. Immunohistochemical profile accorded with the patterns previously observed in salivary gland counterparts. Adjuvant radiotherapy was performed. Neither local recurrences nor metastases have been observed to date.

[Adrenal pseudocyst: clinicopathologic study of a case]. / Seudoquiste adrenal: estudio clínicopatológico de un caso.

Herein we describe a case of a hemorrhagic adrenal pseudocyst that had been initially suspected as being a renal adenocarcinoma. The intraoperative anatomopathological study of the specimen permitted performing conservative surgery. The diagnosis and pathogenesis of this uncommon disease entity are discussed.