Resolución de colección biliar gigante por fistulización espontánea al colon / Resolution of giant biliary collection by spontaneous colon fistulization

El tratamiento de las colecciones biliares puede consistir en actitud expectante con vigilancia radiológica del tamaño y las características de la colección, drenaje percutáneo guiado por pruebas de imagen (eco/TC), drenaje endoscópico dependiendo de la localización y la accesibilidad de la colección, o tratamiento quirúrgico. Se comenta el caso clínico de un hombre intervenido de forma programada realizándose una hepatectomía derecha, que presentó una colección adyacente al lecho quirúrgico, asintomática, sugestiva de bilioma, con aumento progresivo de tamaño, presentando de forma espontánea disminución hasta su resolución por fistulización al ángulo hepático del colon, confirmado por pruebas radiológicas. La formación de fístulas biliares al colon de manera espontánea se debe a la presión extrínseca de la colección sobre la pared intestinal con necrosis de la zona de contacto, siendo su presentación y documentación radiológica excepcionales

The treatment of bile collections is divided into: expectant attitude with radiological monitoring of the size and characteristics of the collection, percutaneous drainage guided by imaging tests (US/CT), endoscopic drainage depending on location and accessibility and surgical treatment. The clinical case of a man undergoing a scheduled hepatectomy was observerd, who presented a large asymptomatic subcapsular collection suggestive of bilioma, with progressive increase in size, spontaneously presenting a decrease until its resolution by fistulization to the hepatic angle of the colon confirmed by Radiological findings. The spontaneously formation of biliary fistulas to the colon is due to the extrinsic pressure of the collection on the intestinal wall with necrosis of the contact zone, being its presentation and radiological documentation exceptional

Resolution of giant biliary collection by spontaneous colon fistulization. / Resolución de colección biliar gigante por fistulización espontánea al colon.

The treatment of bile collections is divided into: expectant attitude with radiological monitoring of the size and characteristics of the collection, percutaneous drainage guided by imaging tests (US/CT), endoscopic drainage depending on location and accessibility and surgical treatment. The clinical case of a man undergoing a scheduled hepatectomy was observerd, who presented a large asymptomatic subcapsular collection suggestive of bilioma, with progressive increase in size, spontaneously presenting a decrease until its resolution by fistulization to the hepatic angle of the colon confirmed by Radiological findings. The spontaneously formation of biliary fistulas to the colon is due to the extrinsic pressure of the collection on the intestinal wall with necrosis of the contact zone, being its presentation and radiological documentation exceptional.

Hemoperitoneo espontáneo relacionado con desgarro de bridas omentales durante la gestación / Spontaneous hemoperitoneum related to tearing of omental flanges

El hemoperitoneo espontáneo idiopático relacionado con intervenciones quirúrgicas previas y durante la gestación es una situación excepcional pudiendo ser letal para madre y feto. A pesar de los avances médicos, la mortalidad por bajo nivel de sospecha sigue manteniéndose alta. Presentamos el caso de una mujer de 36 años en la semana 30 de gestación, sin antecedentes patológicos o traumáticos salvo cesárea previa tres años antes, que acude con inestabilidad hemodinámica y dolor abdominal severo. Se realiza laparotomía de urgencia evidenciando abundante hemoperitoneo sin punto de sangrado excepto un coágulo centinela en epiplón mayor y superficie anterior uterina (AU)

The spontaneous idiopathic hemoperitoneum related to prior surgical procedures and during pregnancy it’s an exceptional situation, lethal to both mother and fetus. Despite medical advances, mortality due to low level of suspicious remains high. We report the case of a 36 year-old woman at 30 weeks gestation with no history of disease or trauma except a previous cesarean three years ago, who presents with hypovolemia signs and severe abdominal pain. Is performed an emergency laparotomy showing hemoperitoneum without bleeding point except a sentinel clot in the omentum and the anterior surface of the uterus (AU)

Differences in the incidence and clinical evolution of early neurotoxicity after liver transplantation based on tacrolimus formulation used in the immunosuppressive induction protocol.

INTRODUCTION: Posttransplant early calcineurin inhibitor (CNI)-induced neurotoxicity (ECIIN) was related to high CNI levels, among other factors. Minimizing exposure could modify its incidence or clinical evolution. OBJECTIVE: To compare the incidence, predisposing factors, and clinical evolution of ECIIN after immunosuppressive induction with low-dose tacrolimus-MR (Advagraf) or conventional dose tacrolimus (Prograf). PATIENTS AND METHODS: We matched 71 patients treated with an immunosuppression induction schedule with basiliximab and low doses of Advagraf (cases group) 1:1 by recipient age and indication for liver transplantation (OLT) with patients treated with a conventional tacrolimus regimen (control group). Baseline characteristics, liver and kidney function, operative technical characteristics, kidney function, and C0 tacrolimus levels at several time points after liver OLT were analyzed. RESULTS: There were 31 cases of ECIIN (21%), 14 in the cases group (20%) and 17 in the control group (24%; P < .001). The incidence of ECIIN was higher in alcoholic liver disease (odds ratio [OR], 8.2; 95% CI, 2.3-28.6; P < .001) and past history of encephalopathy (OR, 2.6; 95% CI, 1.16-5.9; P < .02). Among cases, the incidence of ECIIN was higher when encephalopathy signs were present at time of transplantation (36% vs 12%; P < .001). Control of ECIIN required a switch to cyclosporine therapy in all those in the cases group, whereas this was only needed for 9 cases in the control group (47%; P < .001). CONCLUSION: In this study, although the incidence rate of neurotoxicity induced by Advagraf was lower than the induced by Prograf, it did not respond to routine treatment and required a significantly higher rate of switch to cyclosporine for its control.

Natalizumab y leucoencefalopatía multifocal progresiva: adecuación a las recomendaciones del Ministerio de Sanidad de España / Natalizumab and progressive multifocal leukoencephalopathy: in compliance with the recommendations of the Spanish Ministry of Health

Introducción y Objetivo: Valorar el seguimiento de las recomendaciones emitidas por el ministerio de sanidad dirigidas a minimizar el riesgo de aparación de Leucoencefalopatía Multifocal Progresiva (LMP) asociada al tratamiento con natalizumab por parte de los profesionales sanitarios de nuestro centro. Material y método: Revisión del 100% de pacientes diagnosticados de Esclerosis Múltiple a tratamiento con natalizumab (septiembre 2008-junio 2013). Resultados: 34 pacientes. La duración de tratamiento fue inferior a 1 año en 10 pacientes, entre 1 y 2 años para 11 pacientes y superior a 2 años en 13 pacientes. Se encuentran 24 resultados de serología VJC: positiva 14 y negativa10. Ningún paciente había recibido inmunosupresores y en el 100% de ellos se realizaron resonancias. Fueron informados acerca del riesgo de desarrollar LMP 18 pacientes, 10 con serología VJC positiva llevando 7 de ellos más de dos años a tratamiento con natalizumab. Discusión: Los facultativos se ajustan a las recomendaciones en la gran mayoría de los pacientes sin embargo, la información previa al inicio de tratamiento y una vez alcanzados los 2 años no se realiza de manera extendida. Sería adecuado realizar una estratificación de riesgo en función de presencia o ausencia de determinados factores que permitiría una selección segura y eficaz de la terapia para EM más adecuada para cada paciente

Introduction and Objective: To judge the follow-up of the recommendations made by the Ministry of Health. These recommendations are aimed at minimizing the risk of Progressive Multifocal Leukoencephalopathy (PML) occurrence, which is associated with natalizumab treatments provided by the neurologists of our centre. Methods: Check-up of 100% of the patients diagnosed with multiple sclerosis being treated with natalizumab (September 2008-June 2013). Results: During the study period 34 patients received at least one dose of natalizumab. The duration of the treatment was less than one year for 10 patients between 1 and 2 years for 11 patients, and more than 2 years for 13 patients. 24 results of JCV serology were found, 14 of which were positive and 10, negative. No patient had been given immunosuppressant drugs and resonance tests were done on 100% of them. 18 patients were informed at the risk of developing PML, among whom ten had positive JCV serology. Seven of them, had been treated with natalizumab for more than two years. Discussion: Doctors are following the recommendations with the vast majority of patients. Nevertheless, the information that precedes the treatment and once that the second year of it is reached is not generally provided. Due to the fact that there are currently no tools to predict an individual’s risk of developing PML, it would be appropriate to carry out a risk stratification based on the presence or absence of certain factors that would allow a safe and effective choice of the most appropriate multiple sclerosis therapy for each patient

Charcot-MArie-tooth y analgesia epidural obstétrica, una opción segura / No disponible

No disponible

Implicaciones anestésica en el síndrome de Marshall Smith / No disponible

No disponible

Structure and performance of Awassi and Assaf dairy sheep farms in northwestern Spain.

Data of 69 dairy sheep farms (70% Assaf and 30% Awassi crossbred), located in the Spanish Autonomous Community of Castilla y León and grouped for receiving technical advice, were used to study their structure and performance. Farm surface was 55.4ha, on average. Approximately 25% of the farms did not have cultivation land, and the other 75% had, on average, 73ha (from which 67% were devoted to forage). Farms used 2.1 annual work units (familiar, 90%), 493 ewes, and yielded 147,000 L/yr of milk. Farmers were tenant (84%), younger than 45 yr (70%), had new houses, and were grouped in cooperatives (83%). Sheep were fed indoors (occasional grazing only) in modern loose stalls and had machine milking. Planned mating (summer to fall) was done in 91% of farms (hormonal treatment, 54%) but artificial insemination was scarce (23%). Annual milk sales averaged 309 L/ewe (fat, 6.5%; protein, 5.3%; log(10) somatic cell count, 5.7), and milk was sent to local dairy industries for cheese production, and 1.35 lambs/ewe were harvested as milk-fed lambs (lechazo). Artificial lamb rearing was done in 38% of farms (automatic, 81%; manual, 19%). Total mixed rations were used in 33% of farms, and the rest used rationed concentrate (including self-produced cereals) according to physiological stage of the ewes (0.45 to 1.97 kg/d) and ad libitum forage (dehydrated, 70%; hay, 68%; fresh, 25%; silage, 12%). The concentrate-to-forage ratio ranged between 32 and 61%. In total, 68% of farms bought more than half of the forage, and 87% of them bought more than half of the required concentrates. According to structural, productive, and managerial traits, 4 types of farms were differentiated by using multiple correspondence analysis and cluster analysis. Type groups were: 1) large-surface farms, devoted to cereal and forage production, predominantly with Awassi crossbreed sheep and a high level of self-consumed commodities (12% of the farms); 2) large flocks with intermediate farm surfaces devoted to forage production and predominantly with Assaf sheep (30% of the farms); 3) high-yielding farms, with intermediate sized flocks of Assaf sheep and very intensive management (42% of the farms); and, 4) no-land farms predominantly with Assaf sheep (16% of the farms). In conclusion, the dairy sheep farms studied showed more adoption of intensive production systems than traditional farms, which resulted in higher milk and lamb yields. Despite all of them being based on familiar units, as traditional farms, they were highly dependent on external resources and became more vulnerable, faced with future uncertainties of the market.

Alx3-deficient mice exhibit decreased insulin in beta cells, altered glucose homeostasis and increased apoptosis in pancreatic islets.

AIMS/HYPOTHESIS: Homeodomain transcription factors play an important role in the regulation of pancreatic islet function. In previous studies we determined that aristaless-like homeobox 3 (ALX3) is produced in islet cells, binds to the promoter of the insulin gene and regulates its expression. The purpose of the present study was to investigate the functional role of ALX3 in pancreatic islets and its possible involvement in the regulation of glucose homeostasis in vivo. METHODS: Alx3-knockout mice were used. Glucose and insulin tolerance tests were carried out, and serum insulin concentrations were determined. Isolated islets were used to test insulin secretion and gene expression. The pancreatic islets were also studied using both confocal and conventional microscopy. RESULTS: ALX3 deficiency resulted in increased blood glucose levels and impaired glucose tolerance in the presence of normal serum insulin concentrations. Insulin, glucagon and glucokinase expression were reduced in Alx3-null pancreatic islets. Reduced insulin content was reflected by decreased insulin secretion from isolated islets. Alx3-deficient islets also showed increased apoptosis, and morphometric analyses indicated that they were, on average, of smaller size than islets from control mice. ALX3 deficiency resulted in reduced beta cell mass. Finally, mature Alx3-null mice developed age-dependent insulin resistance due to impaired peripheral insulin receptor signalling. CONCLUSIONS/INTERPRETATION: ALX3 participates in the regulation of the expression of essential genes for the function of pancreatic islets, and its deficiency alters the regulation of glucose homeostasis in vivo. We suggest that ALX3 constitutes a potential candidate to consider in the aetiopathogenesis of diabetes mellitus.

[Oculomotor response to the vertical cephalic autorotatory test in patients with benign paroxistic positional vertigo of the posterior canal]. / Respuesta oculomotora al test de autorrotación cefálica vertical en pacientes con vértigo posicional paroxístico benigno del conducto posterior.

OBJECTIVE: To evaluate the eye movement response to the head auto-rotation test (HART) in the vertical plane in patients with benign paroxysmal positional vertigo. DESIGN: A transversal, descriptive study. SETTING UP: Outpatient clinic in a general Hospital. INDIVIDUALS: 34 posterior canal BPPV cases with a video-oculographic diagnosis, older than 18 years old, 7 of them were not able to perform the HART. INTERVENTION: HART was performed by a an electrooculographic system with simultaneous recording of head movement by an acelerometer in the vertical plane (Vorteq, Micromedical Instruments). The HART with eyes fixation was performed 3 times to determine its reliability. MAIN OUTCOME MEASURES: Gain, asymmetry and phase for the vertical VOR respectively. A statistical analysis was carried out to determine the test reliability and the number of individuals with an abnormal result. RESULTS: Gain is the only variable that showed a reproducible result in the HART for the active head movement at 1-2 Hz (test-retest reliability 0.83-0.89). The values of gain showed a moderate correlation at the frequencies 1-3 Hz (correlation 0.60-0.87). Asymmetry and phase were not reproducible variables (correlation < 0.55). Thirteen of 27 (48%) patients presented a decrease of the vertical gain, another 13 showed normal values and one case showed raised values. CONCLUSION: Gain is the only useful variable in the vertical HART. Forty-eight percent of patients with posterior canal BPPV have a reduced vertical gain, suggesting an impairment of inferior vestibular nerve function.

Respuesta oculomotora al test de autorrotación cefálica vertical en pacientes con vértigo posicional paroxístico benigno del conducto posterior / Oculomotor response to the vertical cephalic autorotatory test in patients with benign paroxistic positional vertigo of the posterior canal

Objetivo: Evaluar la respuesta oculomotora al test de autorrotación cefálica (TARC) en el plano vertical en pacientes con vértigo posicional paroxístico benigno. Pacientes y métodos: Diseño: Estudio descriptivo, transversal. Ámbito del estudio: Hospital general. Individuos: 34 casos VPPB del conducto posterior diagnosticados mediante video-oculografía mayores de 18 años, 7 de los cuales no pudieron realizar el TARC. Intervención: El TARC se realizó mediante un sistema de electrooculografía y registro simultáneo del movimiento cefálico mediante un acelerómetro en el plano vertical (Vorteq, Micromedical Instruments). El TARC activo con fijación de la mirada se realizó en 3 ocasiones para determinar su fiabilidad. Principales medidas de resultados: Ganancia, asimetría y fase para el RVO vertical respectivamente, realizándose un análisis estadístico para la fiabilidad de la prueba, determinándose la proporción de individuos con prueba patológica. Resultados: La ganancia es la única variable que presenta un resultado reproducible en el TARC para el movimiento cefálico activo entre 1-2 Hz (fiabilidad testretest 0,83-0,89). Los valores de la ganancia presentaron una moderada correlación entre las frecuencias 1-3 Hz (correlación 0,60-0,87). La asimetría y la fase no fueron variables reproducibles (correlación < 0,55). Trece de los 27 (48%) pacientes presentaron una disminución de la ganancia vertical, otros 13 presentaron valores dentro de la normalidad y 1 caso valores aumentados. Conclusión: La ganancia es la única variable útil en el TARC vertical. El 48% de los pacientes con VPPB del conducto posterior presentan una disminución de la ganancia vertical, lo que sugiere afectación del nervio vestibular inferior

Objective: To evaluate the eye movement response to the head auto-rotation test (HART) in the vertical plane in patients with benign paroxysmal positional vertigo. Patients and methods: Design: A transversal, descriptive study. Setting up: Outpatient clinic in a general Hospital. Individuals: 34 posterior canal BPPV cases with a video-oculographíc diagnosis, older than 18 years old, 7 of them were not able to perform the HART. Intervention: HART was performed by a an electrooculographic system with simultaneous recording of head movement by an acelerometer in the vertical plane (Vorteq, Micromedical Instruments). The HART with eyes fixation was performed 3 times to determine its reliability. Main outcome measures: Gain, asymmetry and phase for the vertical VOR respectively. A statistical analysis was carried out to determine the test reliability and the number of individuals with an abnormal result. Results: Gain is the only variable that showed a reproducible result in the HART for the active head movement at 1-2 Hz (testretest reliability 0.83-0.89). The values of gain showed a moderate correlation at the frequencies 1-3 Hz (correlation 0.60-0.87). Asymmetry and phase were not reproducible variables (correlation < 0.55). Thirteen of 27 (48%) patients presented a decrease of the vertical gain, another 13 showed normal values and one case showed raised values. Conclusion: Gain is the only useful variable in the vertical HART. Forty-eight percent of patients with posterior canal BPPV have a reduced vertical gain, suggesting an impairment of inferior vestibular nerve function

Análisis ergonómico del puesto de trabajo de una persona con discapacidad física / Ergonomic analysis of a person with physical disabilities: a case report

El objetivo del presente trabajo ha sido verificar mediante análisis ergonómico, si el puesto de trabajo de un cajero con deficiencia física y grave compromiso de la función motora de miembros inferiores estaba adaptado a sus características. Se elaboró un protocolo de análisis ergonómico personalizado, con observación y mediciones del proceso, ambiente de trabajo y entrevistas semiestructuradas. El estudio del caso se realizó en una empresa de transportes del sector minorista de Joao Pessoa, del estado de Paraíba en Brasil, constatándose que el puesto de trabajo reseñado, no estaba adecuado a las características del trabajador objeto de estudio. Los mayores problemas se encontraron en la accesibilidad dentro del lugar de trabajo, mobiliario del puesto y disposición de los equipamientos, que se encontraron inadecuados, favoreciendo posturas y movimientos de riesgo, que contribuyen a agravar la deficiencia física existente y la aparición de nuevas incapacidades

The aim of the present study was to verify, through ergonomic analysis of the work, if the job occupied by a working teller with serious commitment of the motor function in the lower limbs, was ergonomically adapted to the special characteristics of the same one. An ergonomic protocol of analysis of the work adapted to the study for this person was elaborated, it consited in direct and sistematical observation of the process and the atmosphere of work; the study of the case was made in one of the ships of a great company of transport of the retail sector in Brazil. Being stated that the analyzed job was not suitable to the particular characteristics of the working object of the study. The greater problems were in the accessibility within the own place of work, in the furniture and the disposition of the equipment, that were inadequate, favoring positions of risks

[Tongue necrosis as onset of temporal arteritis]. / Necrosis lingual como inicio de la arteritis temporal.

The Horton's disease is a generalized vascular affectation, characterized by a giant cell arteritis. Medium and small caliber arteries are the most frequently affected, mainly of the craneal vascular territory, in particular the collateral branches of the external carotid, and artery in special the superficial temporal artery. We present a case of lingual necrosis as debut of the Horton's disease that has been diagnosed and treated in our ENT Department.

Experiencia preliminar con iontoforesis continua parael tratamiento del dolor localizado / Preliminary experience with continuous iontophoresis for the management of local pain

La iontoforesis es un método basado en la utilización de corriente eléctrica para la administración de fármacos, en forma iónica, a través de la piel, logrando un efecto localizado y minimizando los efectos secundarios. Tradicionalmente se ha aplicado dicha terapia mediante sesiones de 10 a 20 minutos, pero con la nueva forma de administración mediante iontoforesis continua, con el dispositivo Iontopatch®, se logra prolongar la entrega del fármaco entre 12 y 24 horas sin aumentar los efectos secundarios y con mayor comodidad para el paciente. El objetivo de este trabajo consiste en comprobar la validez clínica de la iontoforesis continua mediante el dispositivo Iontopatch® como alternativa a la iontoforesis convencional. Material y métodos: Estudio retrospectivo de 16 pacientes aquejados de epicondilitis, epitrocleítis y metatarsalgias con pobre respuesta al tratamiento convencional con AINE y analgésicos menores no opioides, a los que se les aplicó Iontopatch® conteniendo lidocaína y dexametasona. Valoración del dolor mediante escala visual analógica al inicio, mitad y final del tratamiento. Resultados: Para comparar entre los niveles de dolor basales y posttratamiento se calculó la media y el intervalo de confianza al 95 por ciento, valorando su consistencia con la t de Student, obteniéndose los siguientes resultados: media de EVA basal 7,25 ñ 0,4, media de EVA a mitad de tratamiento 4,4 ñ 0,8 y media de EVA final 1,9 ñ 1,2.Conclusiones: La iontoforesis continua es un método, al menos, tan efectivo como la iontoforesis convencional, lográndose resultados terapéuticos estables sin aumentar los efectos secundarios, ni sistémicos ni locales, con escasas contraindicaciones para su aplicación, y proporcionando mayor comodidad tanto para el paciente como para el clínico (AU)

Manejo del síndrome X con electroestimulación medular. A propósito de un caso clínico / Management of the X syndrome with medullar electrostimulation. Case report

Introducción: el término de "síndrome X" incluye aquellos pacientes que presentan dolor torácico típico con prueba de esfuerzo positiva y arterias coronarias angiográficamente normales, en los que se ha descartado previamente la existencia de espasmo coronario, hipertrofia ventricular izquierda, hipertensión arterial sistémica y enfermedad cardiaca valvular. A lo largo de los años la electroestimulación medular ha mostrado su eficacia en el tratamiento de la angina refractaria. La isquemia miocárdica parece desempeñar un papel en la patogenia del síndrome X. Por esta razón, nos decidimos a aplicar la estimulación medular en uno de nuestros pacientes con esta patología. Caso clínico: mujer de 56 diagnosticada de Síndrome X hace 4 años por presentar dolor retroesternal irradiado a mandíbula, ECG basal normal, ergometría clínica y eléctricamente positiva para la isquemia, radiografía de tórax y ecocardiograma sin alteraciones, zonas de menor captación en la gammagrafía de esfuerzo con talio-201 y arterias coronarias normales en la angiografía. Referida a la unidad del dolor por persistencia de crisis anginosas a pesar del tratamiento médico e ingresos repetidos en cardiología. Se procedió implantación de electroestimulador de cordones posteriores. Se realizaron controles a los dos y seis meses tras la implantación. Desde la implantación del generador la enferma refirió en todas las revisiones una mejoría subjetiva del 100 por ciento. No existieron complicaciones. Conclusiones: en nuestro caso clínico se observó una disminución del número y la intensidad de crisis anginosas, de las necesidades de nitritos y del número de ingresos. Además la técnica fue bien tolerada y no se observaron de complicaciones. Los datos de estudios previos y los resultados obtenidos en nuestro caso clínico demuestran que la electroestimulación medular podría ser útil en el enfoque terapéutico del Síndrome X (AU)