Redox cell signalling triggered by black carbon and/or radiofrequency electromagnetic fields: Influence on cell death.

The capacity of environmental pollutants to generate oxidative stress is known to affect the development and progression of chronic diseases. This scientific review identifies previously published experimental studies using preclinical models of exposure to environmental stress agents, such as black carbon and/or RF-EMF, which produce cellular oxidative damage and can lead to different types of cell death. We summarize in vivo and in vitro studies, which are grouped according to the mechanisms and pathways of redox activation triggered by exposure to BC and/or EMF and leading to apoptosis, necrosis, necroptosis, pyroptosis, autophagy, ferroptosis and cuproptosis. The possible mechanisms are considered in relation to the organ, cell type and cellular-subcellular interaction with the oxidative toxicity caused by BC and/or EMF at the molecular level. The actions of these environmental pollutants, which affect everyday life, are considered separately and together in experimental preclinical models. However, for overall interpretation of the data, toxicological studies must first be conducted in humans, to enable possible risks to human health to be established in relation to the progression of chronic diseases. Further actions should take pollution levels into account, focusing on the most vulnerable populations and future generations.

Genomic features of Pseudomonas sp. RGM2144 correlates with increased survival of rainbow trout infected by Flavobacterium psychrophilum.

This study evaluated the probiotic potential of the biofilm formed by the strain Pseudomonas sp. RGM2144 on rainbow trout survival. When challenged with the fish pathogen Flavobacterium psychrophilum, Pseudomonas sp. RGM2144 increased rainbow trout survival to 92.7 ± 1.2% (control: 35.3 ± 9.5%, p < .0001). The draft genome of Pseudomonas sp. RGM2144 is 6.8 Mbp long, with a completeness 100% and a contamination of 0.4%. The genome contains 6122 protein-coding genes of which 3564 (~60%) have known functions. The genome and phylogeny indicate that Pseudomonas sp. RGM2144 is a new species in the Pseudomonas genus, with few virulence factors, plasmids, and genes associated with antimicrobial resistance, suggesting a non-pathogenic bacterium with protective potential. In addition, the genome encodes for 11 secondary metabolite biosynthetic gene clusters that could be involved in the inhibition of F. psychrophilum. We suggest that Pseudomonas sp. RGM2144 may be applied as a probiotic in salmonid fish farming.

Assessing operating room turnover time via the use of mobile application.

BACKGROUND: Improving operating room (OR) utilization is crucial to hospitals. This study examines the effectiveness of a mobile application co-developed with hospital staff to track OR turnover time (TOT). METHODS: An Android-based app, named ORTimer, was used by staff in two OR units (GI-Lab and D-Core) of Greenville Memorial Hospital (GMH) in South Carolina. The staff used the app to record milestones and note delay reasons (if applicable). A total of 1,782 turnover observations from the GI-Lab and 694 turnover observations from the D-Core were collected for the study. Using data collected from the app and additional information from GMH's electronic medical record system, a two-sample proportionality test was conducted to test the hypothesis that the use of the app improved OR turnover performance (i.e., the TOT is equal to or less than the allotted time). RESULTS: The result of the hypothesis test indicates that a higher percentage of observations in the GI-Lab and D-Core met their turnover target time when the ORTimer app was used. Additionally, multiple regression analysis was used to identify significant factors that contribute to prolonged OR TOT and to estimate their impacts. CONCLUSIONS: The app serves as both a visual management tool as well as a TOT data collection tool. By identifying barriers to the on-time completion of the turnaround, the app allows for continuous improvement of the turnover process.

Exposure to radiation from single or combined radio frequencies provokes macrophage dysfunction in the RAW 264.7 cell line.

PURPOSE: The aim of this study was to determine whether exposure to radiation from single or multiple radio-frequency (RF) signals at 900 and 2450 MHz would induce effects in the RAW 264.7 cell line. MATERIALS AND METHODS: Cell cultures were exposed to single or combined RF for 4, 24, 48, or 72 h in a GTEM electromagnetic test chamber. At the end of the radiation exposure time, viability and cell growth were analyzed by flow cytometry, nitric oxide (NO) production was measured by colorimetry, the expression of HSP70 and TNF-α was ascertained by qPCR, and the phagocytic activity was observed by microscopy. RESULTS: NO production increased after 48 h exposure at 2450 MHz, compared with controls. The group subjected to the combined interaction of two RFs showed an increase of HSP70 after 48 h exposure and a significant increase of NO and TNF-α after 72 h. The phagocytic activity of macrophages decreased in all groups as exposure time increased. CONCLUSIONS: Our results indicated a decrease in phagocytic activity and an increase in inflammatory, cytoprotective, and cytotoxic responses in macrophages after continuous and combined exposure of multiple RF signals. Multiple RF interact in everyday life, the immune response in humans is unknown.

Assessment of the Nurse Medication Administration Workflow Process.

This paper presents findings of an observational study of the Registered Nurse (RN) Medication Administration Process (MAP) conducted on two comparable medical units in a large urban tertiary care medical center in Columbia, South Carolina. A total of 305 individual MAP observations were recorded over a 6-week period with an average of 5 MAP observations per RN participant for both clinical units. A key MAP variation was identified in terms of unbundled versus bundled MAP performance. In the unbundled workflow, an RN engages in the MAP by performing only MAP tasks during a care episode. In the bundled workflow, an RN completes medication administration along with other patient care responsibilities during the care episode. Using a discrete-event simulation model, this paper addresses the difference between unbundled and bundled workflow and their effects on simulated redesign interventions.

Assessment of the Nurse Medication Administration Workflow Process

This paper presents findings of an observational study of the Registered Nurse (RN) Medication Administration Process (MAP) conducted on two comparable medical units in a large urban tertiary care medical center in Columbia, South Carolina. A total of 305 individual MAP observations were recorded over a 6-week period with an average of 5 MAP observations per RN participant for both clinical units. A key MAP variation was identified in terms of unbundled versus bundled MAP performance. In the unbundled workflow, an RN engages in the MAP by performing only MAP tasks during a care episode. In the bundled workflow, an RN completes medication administration along with other patient care responsibilities during the care episode. Using a discrete-event simulation model, this paper addresses the difference between unbundled and bundled workflow and their effects on simulated redesign interventions.

Collision avoidance during group evasive manoeuvres: a comparison of real versus simulated swarms with manipulated vision and surface wave detectors.

Coordinated group motion has been studied extensively both in real systems (flocks, swarms and schools) and in simulations (self-propelled particle (SPP) models using attraction and repulsion rules). Rarely are attraction and repulsion rules manipulated, and the resulting emergent behaviours of real and simulation systems are compared. We compare swarms of sensory-deprived whirligig beetles with matching simulation models. Whirligigs live at the water's surface and coordinate their grouping using their eyes and antennae. We filmed groups of beetles in which antennae or eyes had been unilaterally obstructed and measured individual and group behaviours. We then developed and compared eight SPP simulation models. Eye-less beetles formed larger diameter resting groups than antenna-less or control groups. Antenna-less groups collided more often with each other during evasive group movements than did eye-less or control groups. Simulations of antenna-less individuals produced no difference from a control (or a slight decrease) in group diameter. Simulations of eye-less individuals produced an increase in group diameter. Our study is important in (i) differentiating between group attraction and repulsion rules, (ii) directly comparing emergent properties of real and simulated groups, and (iii) exploring a new sensory modality (surface wave detection) to coordinate group movement.

Inhibition of Flavobacterium psychrophilum biofilm formation using a biofilm of the antagonist Pseudomonas fluorescens FF48.

The most important bacterial pathology currently occurring in Chilean freshwater salmon farming is the cold-water disease produced by the psychrotrophic bacteria Flavobacterium psychrophilum. The main aim of this study was to characterize the inhibitory activity of an antagonist strain on the formation of biofilms of a F. psychrophilum strain. The antagonistic strain Pseudomonas fluorescens FF48 was isolated from the sediment beneath the salmon cages of a freshwater Chilean salmon farm and was identified by using the 16S rRNA gene sequence analysis. The production of siderophores, mainly during the stationary phase of growth of the antagonist strain was demonstrated using the Chrome Azurol S method and through F. psychrophilum inhibition under iron saturation conditions. Subsequently, the effect of the antagonist supernatant on the formation of F. psychrophilum biofilm was tested using the crystal violet staining method observing an inhibition of the growth of F. psychrophilum, but no effect was observed when iron saturation concentrations were used. Furthermore, when the antagonist strain was previously deposited on the support, it completely inhibited the formation of F. psychrophilum biofilms, but when both bacteria were inoculated simultaneously no inhibitory effect was detected. In conclusion, it was demonstrated that FF48 strain is able to inhibit the formation of F. psychrophilum biofilms in vitro probably mediated by the siderophore production, suggesting its potential use as a biocontrol biofilm in freshwater fish rearing systems to prevent the persistence of biofilms of the fish pathogenic species F. psychrophilum.

Morbidity and mortality among heart failure patients in Galicia, N.W. Spain: the GALICAP Study.

OBJECTIVE: Characterization of current morbidity and mortality among heart failure (HF) outpatients in Galicia (N.W. Spain), together with their main determinants. DESIGN: Prospective multicentre study involving 149 primary care physicians. SETTING: Primary care physicians selected randomly from among all (1959) primary care physicians in Galicia. PATIENTS: Clinical and epidemiological information for 1195 outpatients with HF were collected in 2006, with a mean follow-up of 6.5+/-1.5 months. MAIN OUTCOME MEASURES: Survival rates were calculated by Cox's proportional hazard model. RESULTS: Mean patient age was 76 years, 48% were male, 82% had a history of arterial hypertension, and 32% ischaemic cardiopathy. Echocardiography had been performed in 67%, showing preserved systolic function in 61%. Ninety-two (8%) died during follow-up [74 (80%) of them from cardiac causes], and 313 (29%) were re-admitted to hospital [230 (73%) of them for cardiac reasons]. Multivariate analysis identified the following independent predictors of cardiovascular death and/or readmission: ischaemic cardiopathy [hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.29-4.40], stroke (HR 1.79, CI 1.18-2.73), oedema (HR 1.49, CI 1.10-2.03), anaemia (HR 1.66, CI 1.21-2.27), deteriorated systolic function (HR 1.62, CI 1.19-2.20), and previous cardiovascular admissions (HR 2.33, CI 1.67-3.24). Residence in the Barbanza district was identified as an independent predictor of survival free from cardiovascular admission (HR 0.56, CI 0.37-0.86). CONCLUSION: Morbidity and mortality are currently high among Galician HF patients, and their best single predictor is previous hospitalization for cardiovascular reasons.

Gemcitabine plus Paclitaxel versus Paclitaxel monotherapy in patients with metastatic breast cancer and prior anthracycline treatment.

PURPOSE: The objective of this phase III global study was to compare the efficacy of gemcitabine plus paclitaxel (GT) versus paclitaxel in patients with advanced breast cancer. It was designed as a pivotal study for the approval of G for a breast cancer treatment indication. PATIENTS AND METHODS: Patients who relapsed after adjuvant anthracyclines were randomly assigned to gemcitabine,1,250 mg/m(2) days 1 and 8 plus paclitaxel, 175 mg/m(2) on day 1; or, to paclitaxel at same dose on day 1 (both arms administered every 21 days, unblinded). The primary end point was overall survival (OS) and secondary end points were time to progression (TTP), response rate (RR), progression-free survival, response duration, and toxicity. This final OS analysis was planned at 380 deaths. RESULTS: A total of 266 patients were randomly assigned to GT and 263 to paclitaxel. Median survival on GT was 18.6 months versus 15.8 months on paclitaxel (log-rank P = . 0489), with an adjusted Cox hazard ratio of 0.78 (95% CI, 0.64 to 0.96; P = .0187). The TTP was longer (6.14 v 3.98 months; log-rank P = .0002) and the RR was better (41.4% v 26.2%; P = .0002) on GT. There was more grade 3 to 4 neutropenia on GT and grade 2 to 4 fatigue and neuropathy were slightly more prevalent on GT. CONCLUSION: This phase III study documents a role for gemcitabine in advanced breast cancer after anthracycline-based adjuvant therapy. The results establish GT as a reasonable choice for women who require cytoreduction with manageable toxicities and validate ongoing testing of GT in the adjuvant setting.

[Galician study of heart failure in primary care (GALICAP Study)]. / Estudio gallego de insuficiencia cardiaca en atención primaria (estudio GALICAP).

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is an important public health concern. Our aim was to evaluate the characteristics of HF patients in Galicia, Spain. METHODS: This descriptive, cross-sectional, multicenter study involved 149 primary care physicians and recorded the characteristics of 1195 patients diagnosed with HF. RESULTS: Some 48% of patients were male, and their mean age was 76 years, though women were older (P<.001). Disease history included hypertension in 82%, hyperlipidemia in 47%, diabetes in 31%, atrial fibrillation in 49%, valvular disease in 35%, and ischemic heart disease in 32%. Mean systolic and diastolic blood pressures were 131 mm Hg and 76 mm Hg, respectively. Pressure was controlled (

Estudio gallego de insuficiencia cardiaca en atención primaria (estudio GALICAP) / Galician study of heart failure in primary care (GALICAP study)

Introducción y objetivos. La insuficiencia cardiaca (IC) es un importante problema de salud en nuestro medio. Pretendemos conocer las características de estos pacientes en Galicia. Métodos. Estudio descriptivo, transversal, multicéntrico con la participación de 149 médicos de atención primaria, en el que se registraron las características de 1.195 pacientes diagnosticados de IC. Resultados. Un 48% de los pacientes eran varones con una edad media de 76 años, mayor en mujeres (p < 0,001). Presentaba antecedentes de hipertensión el 82%, de dislipidemia el 47%, de diabetes el 31%, de fibrilación auricular el 49%, de valvulopatía el 35% y de cardiopatía isquémica el 32%. Los valores medios de presión arterial sistólica y diastólica fueron, respectivamente, 131 y 76 mmHg, y estaban controlados (≤ 130/80 mmHg) en el 43% de pacientes. El 67% tiene un ecocardiograma, el 61% de ellos con una función sistólica preservada. Al 47% de los pacientes con IC se les realizó una coronariografía, porcentaje superior (p < 0,001) en varones. Los fármacos más prescritos fueron diuréticos (82%), inhibidores de la enzima de conversión de la angiotensina (IECA) (48%), antagonistas de los receptores de la angiotensina II (29%) y bloqueadores beta (27%). En los pacientes con función sistólica deprimida se prescriben más bloqueadores beta (p < 0,001), IECA (p < 0,01) y antialdosterónicos (p < 0,05). Durante el último año, el 57% de los pacientes estuvieron ingresados, el 45% de ellos por causa cardiovascular. Conclusiones. La IC con función sistólica preservada es la forma más prevalente en Galicia, que está mayoritariamente asociada con una presión arterial elevada siendo, su control limitado. En pacientes con cardiopatía isquémica, el sexo influye en la realización de coronariografía. La prescripción de fármacos no es óptima. Es necesario promover estrategias para mejorar el cuidado de estos pacientes (AU)

Introduction and objectives. Heart failure (HF) is an important public health concern. Our aim was to evaluate the characteristics of HF patients in Galicia, Spain. Methods. This descriptive, cross-sectional, multicenter study involved 149 primary care physicians and recorded the characteristics of 1195 patients diagnosed with HF. Results. Some 48% of patients were male, and their mean age was 76 years, though women were older (P<.001). Disease history included hypertension in 82%, hyperlipidemia in 47%, diabetes in 31%, atrial fibrillation in 49%, valvular disease in 35%, and ischemic heart disease in 32%. Mean systolic and diastolic blood pressures were 131 mm Hg and 76 mm Hg, respectively. Pressure was controlled (≤ 130/80 mm Hg) in 43% of patients. Overall, 67% underwent echocardiography, of whom 61% had preserved systolic function. Coronary angiography was performed in 47% of patients with ischemic heart disease, more frequently in males than females (P<.001). The most commonly prescribed drugs were diuretics (82%), angiotensin-converting enzyme (ACE) inhibitors (48%), angiotensin II receptor antagonists (29%), and beta-blockers (27%). Patients with depressed systolic function were more frequently prescribed beta-blockers (P<.001), ACE inhibitors (P<.01), and antialdosterones (P<.05). During the last year, 57% of patients had been admitted to hospital, of whom 45% were admitted for cardiovascular reasons. Conclusions. The most prevalent form of HF in Galicia was HF with preserved systolic function, which was mostly associated with high blood pressure due to poor control. In patients with ischemic heart disease, the use of coronary angiography was influenced by sex. Drug treatment was suboptimal. Intervention programs are required to improve care in these patients (AU)

Carcinoma papilar quístico y del tiroides: estudio de 4 casos / Cystic papillary and thyroid carcinoma: a four-cases study

Se presentaron 4 casos de carcinoma papilar quístico en el período de 4 años. Se realizó examen físico de todos los casos; se encontró una masa cervical firme en la cara anterior del cuello y en 2 de ellos, se palparon adenopatías cervicales. Se aplicaron técnicas de imagen (ecografía cervical y gammagrafía tiroidea); se completó el estudio con BAAF, que tuvo valor diagnóstico en el 75 por ciento de los casos. Se realizó un estudio anatomopatológico de todas las piezas obtenidas. Se hizo la resección del quiste, biopsia intraoperatoria y si se confirmó el diagnóstico de carcinoma papilar quístico, se le realizó una tiroidectomía total y si fue necesario, linfadenectomía. Se completó el tratamiento con I131 a dosis ablativa y tratamiento hormonal supresor de la TSH. Se destacó el papel de la BAAF en el estudio preoperatorio(AU)

Carcinoma papilar quístico y del tiroides: Estudio de 4 casos / Tryroid cyst papillary carcinoma: Study of four cases

Se presentaron 4 casos de carcinoma papilar quístico en el período de 4 años. Se realizó examen físico de todos los casos; se encontró una masa cervical firme en la cara anterior del cuello y en 2 de ellos, se palparon adenopatías cervicales. Se aplicaron técnicas de imagen (ecografía cervical y gammagrafía tiroidea); se completó el estudio con BAAF, que tuvo valor diagnóstico en el 75 % de los casos. Se realizó un estudio anatomopatológico de todas las piezas obtenidas. Se hizo la resección del quiste, biopsia intraoperatoria y si se confirmó el diagnóstico de carcinoma papilar quístico, se le realizó una tiroidectomía total y si fue necesario, linfadenectomía. Se completó el tratamiento con I131 a dosis ablativa y tratamiento hormonal supresor de la TSH. Se destacó el papel de la BAAF en el estudio preoperatorio.

4 cases of cyst papillary carcinoma in a period of 4 years were presented. All of them underwent physical examination. A firm cervical mass was found in the anterior side of the neck and cervical adenopathies were palpated in 2 of them. Imaging techniques (cervical echography and thyroid gammagram) were applied. The study was completed with FNAB, which had a diagnostic value in 75 % of the cases. An anatomopathological study of all the pieces obtained was conducted. Resection of the cyst and intraoperatory biopsy were performed. In those cases with confirmed diagnosis of cyst papillary carcinoma, total thyroidectomy was carried out and, if necessary, lymphadenectomy. The treatment was concluded with I131 at ablative doses and TSH -supressing hormonal treatment. The role of FNAB in the preoperative study was stressed.

Resultados del diagnóstico de la patología nodular tiroidea / Results of the diagnosis of thyroid nodular pathology

Se realizó un estudio prospectivo que incluyó a 204 pacientes afectados por enfermedad nodular tiroidea, diagnosticada en el Hospital Clinicoquirúrgico "Hermanos Ameijeiras", en el periodo de mayo de 1997 a mayo de 2000 y donde se evaluó el resultado de los medios diagnósticos. El mayor número de pacientes se encontraba en la 5ta. y 4ta. década de la vida, 53 y 49 (por ciento) respectivamente; el sexo femenino fue el más frecuente, para el 90,7(por ciento). A todos los pacientes se les realizó para su evaluación la biopsia aspirativa con aguja fina y el ultrasonido. El bocio multinodular (46,1 (por ciento) y el adenoma folicular (21,1 (por ciento) constituyeron las afecciones benignas más frecuentes y entre las malignas el carcinoma papilar (5,9 (por ciento). Al 66,7 (por ciento) de los casos se les detectó tumoración sólida, y fue el lóbulo derecho el lugar más afectado para el 41,6 (por ciento). La biopsia espirativa con aguja fina mostró 90,9 (por ciento) de sensibilidad, 99,1 (por ciento) de especificidad y una eficacia de 98,4(por ciento)(AU)

Resultados del diagnóstico de la patología nodular tiroidea / Results of the diagnosis of thyroid nodular pathology

Se realizó un estudio prospectivo que incluyó a 204 pacientes afectados por enfermedad nodular tiroidea, diagnosticada en el Hospital Clinicoquirúrgico "Hermanos Ameijeiras", en el periodo de mayo de 1997 a mayo de 2000 y donde se evaluó el resultado de los medios diagnósticos. El mayor número de pacientes se encontraba en la 5ta. y 4ta. década de la vida, 53 y 49 (por ciento) respectivamente; el sexo femenino fue el más frecuente, para el 90,7(por ciento). A todos los pacientes se les realizó para su evaluación la biopsia aspirativa con aguja fina y el ultrasonido. El bocio multinodular (46,1 (por ciento) y el adenoma folicular (21,1 (por ciento) constituyeron las afecciones benignas más frecuentes y entre las malignas el carcinoma papilar (5,9 (por ciento). Al 66,7 (por ciento) de los casos se les detectó tumoración sólida, y fue el lóbulo derecho el lugar más afectado para el 41,6 (por ciento). La biopsia espirativa con aguja fina mostró 90,9 (por ciento) de sensibilidad, 99,1 (por ciento) de especificidad y una eficacia de 98,4(por ciento)

A prospective study that included 204 patients affected by thyroid nodular disease diagnosed at "Hermanos Ameijeiras" Clinical and Surgical Hospital from May, 1977, to May, 2000, was conducted. Most of the patients were in the 4th or 5th decade of life, 53 and 49 percent, respectively. Females prevailed with 90.7 percent. All the patients underwent fine needle aspiration biopsy and ultrasound for their evaluation. The multinodular goiter (41,6 percent) and the follicular adenoma (21.1 percent) were the most frequent bening affections; whereas the papillary carcinoma was the commonest among the malignant. Solid tumors were detected in 66.7 percent of the cases. The right lobule was the most affected place, accounting for 41.6 percent. Fine needle aspiration biopsy showed 90.9 percent of sensitivity, 99.1 percent of specificity and an efficiency of 98.4 percent(AU)

Protocolo de diagnóstico y tratamiento del cáncer tiroideo / Protocol of diagnosis and treatment of thyroid cancer

En este trabajo se plasma el manejo de los pacientes con de cáncer del tiroides, teniendo en cuenta, el uso de los medios diagnósticos, en particular la importancia del uso de la biopsia aspirativa con aguja fina para el diagnóstico precoz. Se sabe que en las últimas décadas han existido criterios más conservadores en lo referido a la suficiencia en la extensión de la operación, en los cánceres bien diferenciados, motivado esto por el mayor conocimiento de la biología del tumor, el desarrollo de pruebas de inmunohistoquímica, tratamiento adyuvante y un seguimiento más estrecho. Por lo que esto ha motivado ciertos criterios controvertidos. Se expone un protocolo de diagnóstico y tratamiento, teniendo en cuenta un adecuado estadiamiento, y definición de los grupos de riesgo, parámetro importante y novedoso en esta entidad(AU)

Protocolo de diagnóstico y tratamiento del cáncer tiroideo / Protocol of diagnosis and treatment of thyroid cancer

En este trabajo se plasma el manejo de los pacientes con de cáncer del tiroides, teniendo en cuenta, el uso de los medios diagnósticos, en particular la importancia del uso de la biopsia aspirativa con aguja fina para el diagnóstico precoz. Se sabe que en las últimas décadas han existido criterios más conservadores en lo referido a la suficiencia en la extensión de la operación, en los cánceres bien diferenciados, motivado esto por el mayor conocimiento de la biología del tumor, el desarrollo de pruebas de inmunohistoquímica, tratamiento adyuvante y un seguimiento más estrecho. Por lo que esto ha motivado ciertos criterios controvertidos. Se expone un protocolo de diagnóstico y tratamiento, teniendo en cuenta un adecuado estadiamiento, y definición de los grupos de riesgo, parámetro importante y novedoso en esta entidad(AU)

In this paper, the management of patients with thyroid cancer is dealt with taking into account the use of the diagnostic tools and, in particular, the importance of the use of fine-needle aspiration biopsy for the early diagnosis. In the last decades, there have been more conservative criteria regarding the sufficiency in the extension of surgery in the well differentiated cancers, motivated by the greater knowledge of tumor biology, the development of immunohistochemical tests, adjuvant treatment and a closer follow-up. This has led to the appearance of certain controversial criteria. A protocol of diagnosis and treatmemt is exposed taking into consideration an adequate staging and definition of the risk groups, an important and novel parameter in this entity(AU)