Advances in the Immunobiological Therapies for Advanced Melanoma. / Nuevos avances de tratamiento inmunobiológico en el melanoma avanzado.

Metastatic or locally advanced unresectable melanoma carries a high morbidity and mortality. However, notable advances have been made in recent years in the systemic treatment of this disease, with the appearance of targeted therapy using tyrosine kinase inhibitors that block the mitogen activated protein kinase pathway, and of modern immunotherapy with immune-modulating monoclonal antibodies. In this paper, we provide an update of available data on new immune therapies and we review the clinical development that led to their approval for use in routine clinical practice.

[Clinical and economic repercussions of the use of tunneled haemodialysis catheters in a health area]. / Repercusiones clínicas y económicas del uso de catéteres tunelizados de hemodiálisis en un área sanitaria.

INTRODUCTION: Tunneled catheters in hemodialysis are associated with poor prognosis, however, few prospective studies have been designed to specifically evaluate this aspect. The objective has been evaluate the impact of tunneled catheter in patient mortality and costs attributable to this procedure. METHODS: A seven years prospective cohort study was performed in all patients starting hemodialysis in our health care area adjusting for comorbidity and albumin. The study comprised 260 patients with Charlson index 7.05 +/- 2.8 (age 65.5 years, 62.3% males, 25% with diabetes mellitus and 37.7% with a previous cardiovascular event. RESULTS: The first vascular access was a catheter in 47.3%, PTFE in 11.2% and native arteriovenous fistula in 41.5%. Minimum follow-up was one year, with an average of 2.31 years/patient. The mortality risk adjusted for comorbidity was greater among the patients that started with catheterization, HR: 1.86 [1.11-3.05]. This negative effect was observed in 57.30% of those subjected to catheterization at any stage (HR: 1.68 [1.00-2.84] and proved to be time dependent, i.e., the longer catheterization, the greater the risk: HR: 7.66 [3.34-17.54] third versus first tertil. The cost directly attributable to catheter use was 563.31 euros/month. All poor prognosis groups showed lower albumin and hemoglobin levels, without differences in efficacy. CONCLUSION: Tunneled catheter use at any time is associated with an increased risk of death. This effect increases with the duration of catheterization, both circumstances are independent of patient comorbidity at time start of hemodialysis and implies a higher net cost.

Repercusiones clínicas y económicas del uso de catéteres tunelizados de hemodiálisis en un área sanitaria / No disponible

Introducción: el uso de catéteres en hemodiálisis se asocia a un gran número de complicaciones. Sin embargo, se han realizado pocos estudios diseñados específicamente para evaluar este problema. Los objetivos del estudio han sido conocer el impacto en la supervivencia del paciente y el gasto económico que implica la utilización de catéteres. Métodos: estudio observacional y prospectivo histórico de siete años de duración en 260 pacientes incidentes en hemodiálisis en nuestra área de salud, ajustado a la comorbilidad y albúmina al inicio de la hemodiálisis. La media de edad fue de 65,5 ± 15,2 años, 62,3% varones, 25% diabéticos. La media del índice de comorbilidad de Charlson fue de 7,05 ± 2,8. Resultados: el 47,3% de los pacientes inicia hemodiálisis con catéter, el 41,5% con FAV-auto y 11,2% con FAV-PTFE. El seguimiento medio fue 2,31 años/paciente. El riesgo de mortalidad ajustado por comorbilidad fue mayor para los que inician hemodiálisis con un catéter, HR:1,86 (1,11-3,05). Este efecto negativo también se observó en el 57,3% de pacientes que a lo largo del seguimiento requirieron un catéter, HR: 1,68 (1,00-2,84) y, además, fue tiempo dependiente; a mayor tiempo con catéter, mayor mortalidad: HR 7,66 (3,34-17,54), tertil 3 vs. tertil 1. El coste del empleo mes/catéter fue de 561,31 euros. Conclusiones: el uso de catéteres tunelizados es un factor independientemente asociado con la mortalidad de los pacientes, tanto al inicio como a lo largo del seguimiento, es tiempo dependiente y conlleva un elevado coste económico (AU)

Introducction: Tunneled catheters in hemodialysis are associated with poor prognosis, however, few prospective studies have been designed to specifically evaluate this aspect. The objective has been evaluate the impact of tunneled catheter inpatient mortality and costs attributable to this procedure. Methods: A seven years prospective cohort study was performed in all patients starting hemodialysis in our health care area adjusting for comorbidity and albumin. The study comprised 260patients with Charlson index 7.05 ± 2.8 (age 65.5 years, 62.3%males, 25% with diabetes mellitus and 37.7% with a previous cardiovascular event. Results: The first vascular access was a catheter in 47.3%, PTFE in 11.2% and native arteriovenous fistula in 41.5%. Minimum follow-up was one year, with an average of 2.31 years/patient. The mortality risk adjusted for comorbidity was greater among the patients that started with catheterization, HR: 1.86 [1.11-3.05]. This negative effect was observed in 57.30% of those subjected to catheterization at any stage (HR: 1.68 [1.00-2.84] and proved to be time dependent, i.e., the longer catheterization, the greater the risk: HR:7.66 [3.34-17.54] third versus first tertil. The cost directly attributable to catheter use was 563.31 euros/month. All poor prognosis groups showed lower albumin and hemoglobin levels, without differences in efficacy. Conclusion: Tunneled catheter use at any time is associated with an increased risk of death. This effect increases with the duration of catheterization, both circumstances are independent of patient comorbidity at time start of hemodialysisand implies a higher net cost (AU)

[Prospective monitoring of vascular access in hemodialysis by means of a multidisciplinary team]. / Seguimiento prospectivo del acceso vascular en hemodialisis mediante un equipo multidisciplinar.

PURPOSE: Nowadays, expert guidelines recommend the monitoring programs of the vascular access (VA) by a multidisciplinary team. MATERIAL AND METHOD: We present the experience over the last five years, of a prospective VA surveillance by a multidisciplinary team. The quality indicators reached are described as the associated factors for survival of the new VA. RESULTS: Three hundred seventeen VA have been studied, 73% were arteriovenous fistulas(AVF) and the rest were polytetrafluoroethylene (PTFE) grafts at 282 patients. The main causes of dysfunctions were elevated dynamic venous pressure (42.5%) and the decreased blood flow (36.4%) with a 88% of positive predictive value. Over the 5 years there was 88 thrombosis (24 AVF and 64 PTFE grafts), that means a hazard thrombosis global rate of 0.15 access/year, which were distributed in 0.06 for AVF and 0.38 in PTFE grafts. Two hundred and one repairs of VA were done: 66.6% were elective repair after a proper review by the multidisciplinary team and the rest of them were done after the AV thrombosis happened. Urgent rescue surgeries were done in 76% of the thrombosis. 62.5% of the patients did not need a catheter after vascular access thrombosis. The complication relation with AVF and PTFE were 11.4% of the total patients hemodialysis hospitalizations. 65.2% of the VA were new access. 57% of patients were properly reviewed in the pre-dialysis unit at least once and 80% of them start haemodialysis with a mature access. The average survival (Kaplan Meier) of the new AVF was 1,575+/-55 days vs 1,087+/-102 of the PTFE grafts (p < 0.008). The survival after 1, 2 and 3 years for the AVF was 89%, 85% and 83% and for the PTFE graft 3% 67% and 51% respectively. The Cox regression has proved that the type of vascular access is the strongest factor associated to VA survival. The survival added of VA repaired due to dysfunction was 1,062 +/- 97 days vs 707 +/- 132 due to thrombosis, log rank 5.17 (p < 0,02). The increasing risk of those repaired after a thrombosis vs dysfunction is 4.2 p < 0,01. CONCLUSIONS: The monitoring of the vascular access by a multidisciplinary team has reached:low rate of thrombosis, high elective number of repairs of the VA, high urgent rescue surgery after a thrombosis and a few number catheter needed and hospitalizations. AVF are associated with greater survival than PTFE. The VA repair due to dysfunction vs thrombosis had a greater survival as well.

Faecal incontinence in children with spina bifida: the best conservative treatment.

Incontinence is one of the major stigmata affecting the quality of life of the myelodysplastic patient. The appropriate management of the neuropathic bladder has led most patients to survive with good conditions. Major advances have also been made in the treatment of faecal incontinence for enabling patients to achieve their full potential, to become integrated in society and to be as independent as possible. We present the results of the Retrograde Colonic Enema (RCE) in 33 patients suffering neurogenic faecal incontinence. We believe that the RCE is one of the best conservative methods of treatment for relieving faecal incontinence originating from spina bifida and other neurological problems with intestinal dysfunction.