Thrombocytopenia after Aortic Valve Replacement with Perceval S Sutureless Bioprosthesis.

BACKGROUND AND AIM OF THE STUDY: Sutureless aortic bioprosthetic valves have become an alternative to conventional bioprostheses in high surgical risk cases. A significant decline in platelet count during the immediate postoperative period was observed in cases of Perceval S sutureless aortic valve implantation. The study aim was to determine how the reduction in platelet count after Perceval S prosthesis implantation compared to that after other bioprosthesis implants. METHODS: Between July 2011 and July 2014, a total of 77 isolated biological aortic valve replacements (AVRs) was performed at the authors' institution. These included 27 Perceval S prostheses (35.1%) and 50 Mitroflow prostheses (64.9%). Platelet counts and mean platelet volumes (MPVs) were determined on the day before surgery (T0) and at 24 h (T1), 48 h (T2) and 72 h (T3) after surgery. RESULTS: There were no significant differences in inhospital mortality (three Perceval S (11.1%) versus four Mitroflow 8%); p = 0.65), nor in morbidity between groups. A total of 16 patients (20.8%) had severe postoperative thrombocytopenia (<50×103/mm3). The incidence of severe thrombocytopenia was significantly higher (p = 0.046) in Perceval S patients (n = 9; 33.3%) than in Mitroflow patients (n = 7; 14%). The platelet count recovered in all patients with severe thrombocytopenia. In an adjusted-propensity multivariate logistic regression analysis, the Perceval S prosthesis was the major independent predictor of severe thrombocytopenia after AVR (OR 0.06, 95% CI: 0008-0.5, p = 0.009). CONCLUSION: Aortic bioprosthesis implantation with the Perceval S sutureless bioprosthesis appears to be associated with the occurrence of postoperative thrombocytopenia, though without any clinical implication for the patients. Prospective randomized trials are required to confirm these data.

Primary and metastatic renal hemangiopericytoma.

OBJECTIVE: Haemangiopericytoma is an uncommon perivascular tumor that occurs more frequently in soft tissues and is extremely rare in the kidney. METHODS: We report two cases: The first one is the case of a 57-year-old man with bilateral metastatic renal haemangiopericytoma which appeared 18 years after removal of a meningeal haemangiopericytoma. The second is a 29-year-old woman with a primary kidney haemangiopericytoma that was casually found in a nephrectomy piece. RESULTS: In the first case, radical left nephrectomy and right renal mass radiofrequency ablation were performed. The patient had an uneventful postoperatory recovery. He remained disease-free 22 months after surgery but two new lesions appeared that were treated with radiofrequency ablation. The second case was a casual finding, a small tumor that had been totally resected. CONCLUSIONS: Haemangiopericytoma is a rare tumor with an uncertain clinical behaviour. Long-term follow up is important as local recurrences and metastases can develop years after initial treatment.

Urinary incontinence during pregnancy and postpartum. Associated risk factors and influence of pelvic floor exercises.

OBJECTIVES: To determine the prevalence of urinary incontinence (UI) before pregnancy, in the third trimester and postpartum. To analyze its influence on quality of life and associated potential risk factors and the efficacy of pelvic floor exercises. METHODS: Prospective study in 413 pregnant women. The modified ICIQ-SF incontinence questionnaire was given to the pregnant women at the end of the third quarter. This questionnaire was administered by telephone at 3 and 6 months postpartum. The influence of several risk factors for UI in pregnancy and postpartum were analyzed. Patients with persistent UI at 6 months postpartum were trained to do pelvic floor exercises. RESULTS: Patients with UI before pregnancy were excluded from the study. UI in the third trimester was 31%. Analyzed risk factors did not condition a higher percentage of UI. Prevalence of UI was 11.3% at 3 months postpartum and 6.9% at 6 months. 70% of the incontinent patients already had it during pregnancy and it appeared de novo post-delivery in 30% of the patients. Prevalence of UI after delivery was higher in women with UI in pregnancy and lower in caesarean cases. Most women improved with pelvic floor exercises. CONCLUSIONS: Analysed risk factors did not significantly increase UI in pregnancy. Prevalence of UI after delivery is higher in women with UI in pregnancy and lower in caesarean cases. Postpartum pelvic floor exercises for three months in patients with persistent stress UI at 6 months postpartum clearly improved the degree of continence.

A harmonized database of European forest simulations under climate change.

Process-based forest models combine biological, physical, and chemical process understanding to simulate forest dynamics as an emergent property of the system. As such, they are valuable tools to investigate the effects of climate change on forest ecosystems. Specifically, they allow testing of hypotheses regarding long-term ecosystem dynamics and provide means to assess the impacts of climate scenarios on future forest development. As a consequence, numerous local-scale simulation studies have been conducted over the past decades to assess the impacts of climate change on forests. These studies apply the best available models tailored to local conditions, parameterized and evaluated by local experts. However, this treasure trove of knowledge on climate change responses remains underexplored to date, as a consistent and harmonized dataset of local model simulations is missing. Here, our objectives were (i) to compile existing local simulations on forest development under climate change in Europe in a common database, (ii) to harmonize them to a common suite of output variables, and (iii) to provide a standardized vector of auxiliary environmental variables for each simulated location to aid subsequent investigations. Our dataset of European stand- and landscape-level forest simulations contains over 1.1 million simulation runs representing 135 million simulation years for more than 13,000 unique locations spread across Europe. The data were harmonized to consistently describe forest development in terms of stand structure (dominant height), composition (dominant species, admixed species), and functioning (leaf area index). Auxiliary variables provided include consistent daily climate information (temperature, precipitation, radiation, vapor pressure deficit) as well as information on local site conditions (soil depth, soil physical properties, soil water holding capacity, plant-available nitrogen). The present dataset facilitates analyses across models and locations, with the aim to better harness the valuable information contained in local simulations for large-scale policy support, and for fostering a deeper understanding of the effects of climate change on forest ecosystems in Europe.

Fibrous pseudotumor affecting the tunica vaginalis, epididymis and seminal duct.

OBJECTIVE: To report one case of advanced fibrous pseudotumour. METHODS: A 34-year-old patient presented with a painless lump on the right side of the scrotum. Examination revealed a hard tissue thickening attached to the tail and body of the right epididymis. The results of the ultrasound study were not clear and multiple differential diagnosis were considered. The lesion was surgically removed by partial right epididymectomy and resection of the affected tunica vaginalis and ductus deferens for anatomopathological study. RESULTS: The histopathological study revealed an evolved fibrous pseudotumour with bone metaplasia. CONCLUSION: Fibrous pseudotumour is a benign paratesticular lesion that grows slowly and painlessly. It is usually diagnosed by chance or in associated processes such as hydrocele. Differential diagnosis with malignant tumors avoids unnecessary radical treatment.

Testicular cancer: our experience after 10 years.

OBJECTIVES: Testicular cancer represents about 1% of malignant tumors in men. Of these tumors 95% are germ cell tumors (GCTs), which have a maximum incidence between the second and third decades of life. Our objective was to carry out a retrospective analysis of testicular tumor cases that had been diagnosed in our Health Area between the years 2000 and 2010. METHODS: We performed a retrospective descriptive study between the years 2000 and 2010 analyzing 43 patients treated for testicular cancer, including in the analysis tumor incidence, the patient's age, clinic attended, patient's time until appointment, presence of tumor markers, patient's time before treatment, use of testicular prostheses, histological type and their typical characteristics, oncological treatment, tumor progression and mortality rate. RESULTS: We found an incidence of 4-5 cases/100,000 population/year in our Health Area. Two-thirds of the cases were detected in Stage I, and 100% of these cases showed complete remission. Among those with higher stage tumors, two out of three patients were cured after chemotherapy. For the remaining one-third, rescue treatments managed to achieve a remission rate of 66%. Mortality was low and was linked to lymphoma or metastatic dissemination. CONCLUSION: The trend towards early diagnosis with detection during the initial cancer stages, together with current chemotherapy protocols, enables a high cure rate for testicular cancer. Mortality in our series was associated with primary or secondary lymphomas.

Using M-learning on nursing courses to improve learning.

Modern handheld devices and wireless communications foster new kinds of communication and interaction that can define new approaches to teaching and learning. Mobile learning (m-learning) seeks to use them extensively, exactly in the same way in which e-learning uses personal computers and wired communication technologies. In this new mobile environment, new applications and educational models need to be created and tested to confirm (or reject) their validity and usefulness. In this article, we present a mobile tool aimed at self-assessment, which allows students to test their knowledge at any place and at any time. The degree to which the students' achievement improved is also evaluated, and a survey on the students' opinion of the new tool was also conducted. An experimental group of 20- to 21-year-old nursing students was chosen to test the tool. Results show that this kind of tool improves students' achievement and does not make necessary to introduce substantial changes in current teaching activities and methodology.

Using m-learning on nursing courses to improve learning.

Modern handheld devices and wireless communications foster new kinds of communication and interaction that can define new approaches to teaching and learning. Mobile learning (m-learning) seeks to use them extensively, exactly in the same way in which e-learning uses personal computers and wired communication technologies. In this new mobile environment, new applications and educational models need to be created and tested to confirm (or reject) their validity and usefulness. In this article, we present a mobile tool aimed at self-assessment, which allows students to test their knowledge at any place and at any time. The degree to which the students' achievement improved is also evaluated, and a survey on the students' opinion of the new tool was also conducted. An experimental group of 20- to 21-year-old nursing students was chosen to test the tool. Results show that this kind of tool improves students' achievement and does not make necessary to introduce substantial changes in current teaching activities and methodology.

Calcified renal artery aneurism embolization in a solitary kidney.

OBJECTIVE: To review presentation, diagnosis and treatment of renal artery aneurysms, a very uncommon disease. METHODS: We report the case of a male with a calcified renal artery aneurysm in a solitary kidney. RESULTS: Symptomatic effects may be hypertension, hematuria or flank pain. Arteriosclerosis and medial dysplasia are the most frequent causes and diagnosis is based on CT scan and angiography. CONCLUSIONS: The renal artery aneurysm is a disease with low prevalence and there is no clear protocol for management. The number of cases has increased over the last decades and endovasculrar treatment is a good therapeutic option.

[Relevance of clinical and serum parameters on severe urinary sepsis after renal obstruction.] / Importancia de los parámetros clínicos y analíticos de la sepsis grave en la uropatía obstructiva.

INTRODUCTION: Urosepsis is an underdiagnosed entity with high morbidity and mortality and significant associated costs. The delay in diagnosis leads to an increased risk of multiorgan failure and death. Although its prognosis is better than that of other sepsis, the mortality rate is 20 - 40%. OBJECTIVE: Describe the obstructive uropathy cases (OU) that are complicated by severe sepsis (SS) and identify early biomarkers of SS. MATERIAL AND METHODS: Observational and prospective study of 65 patients with urgent high OU. All patients were evaluated at three different times (0, 24 and 48 hours). An SS predictor model has been constructed and a multivariate risk analysis has been carried out. RESULTS: 64.61% (n=42) developed SS (NSS: n=13). The only statistically significant variables in the 3 moments evaluated and that obtained a good area under the curve [AUROC (>0.70)] were the elevation of neutrophils, procalcitonin, and decrease of bicarbonate. At the time of patient admission, the variable that best predicted SS was the elevation of procalcitonin (AUROC:0.919). SS risk factors (p<0.005) were the history of cancer immunosuppression, and/or urinary tract surgeries, complete UO and high blood values of lactate, potassium and decrease of bicarbonate. The potassium-lactate combination on admission predicted SS with a probability function of 0.805. CONCLUSIONS: There is an analytical profile maintained over the time characteristic of SS that allows anearly identification of patients with OU subsidiary of been complicated with SS.

INTRODUCCIÓN: La Sepsis urinaria obstructiva (SUO) es una entidad infradiagnosticada con una elevada morbimortalidad e importantes costes asociados. El retraso en su diagnóstico condiciona un mayor riesgo de fracaso multiorgánico y fallecimiento. Aunque su pronóstico es mejor que el de otros focos de sepsis, su mortalidad es del 20 - 40%. OBJETIVO: Describir los cuadros de uropatía obstructiva (UO) que se complican con sepsis grave (SG) e identificarlos biomarcadores diagnósticos de SG en la UOde forma precoz.MATERIAL Y MÉTODOS: Estudio observacional y prospectivo de 72 pacientes con UO alta ingresados de manera urgente en el Servicio de Urología del Hospital Clínico Universitario de Valladolid. Todos los pacientes del estudio fueron evaluados en tres momentos diferentes (0, 24 y 48 horas). Se ha creado un modelo predictor de SG y se ha realizado un análisis multivariante de riesgo. RESULTADOS: El 64,61% de los pacientes (n=42) desarrolló SG (NSG: n=13). Las únicas variables estadísticamente significativas en los tres momentos evaluados y que obtenían una buena área bajo la curva [AUROC (>0,70)] fueron la elevación de neutrófilos y procalcitonina y la disminución de bicarbonato. En el momento del ingreso la variable que mejor predecía SG fue la elevación de procalcitonina (AUROC: 0,919). Los factores de riesgo de SG (p<0,05) fueron los antecedentes de cáncer, la inmunosupresión y/o cirugías de vías urinarias, la UO completa y los valores elevados en sangre de lactato y potasio y la disminución del bicarbonato en la gasometría venosa. La combinación potasio-lactato al ingreso predecía SG con una función de probabilidad de 0,805. CONCLUSIONES: Existe un perfil analítico, mantenido en el tiempo, característico de SG que permite la identificación precoz de los pacientes con UO subsidiarios de complicarse con SG.

Synthesis of Calcium Aluminates from Non-Saline Aluminum Dross.

The present work examines the synthesis of tricalcium aluminate (for use as a synthetic slag) from the non-saline dross produced in the manufacture of metallic aluminum in holding furnaces. Three types of input drosses were used with Al2O3 contents ranging from 58 to 82 wt %. Calcium aluminates were formed via the mechanical activation (reactive milling) of different mixtures of dross and calcium carbonate, sintering at 1300 °C. The variables affecting the process, especially the milling time and the Al2O3/CaO molar ratio, were studied. The final products were examined via X-Ray diffraction (XRD), scanning electron microscopy (SEM), transmission electron microscopy (TEM) and Raman spectroscopy. The reactive milling time used was 5 h in a ball mill, for a ball/dross mass ratio of 6.5. For a molar relationship of 1:3 (Al2O3/CaO), sintered products with calcium aluminate contents of over 90% were obtained, in which tricalcium aluminate (C3A) was the majority compound (87%), followed by C12A7 (5%).

[The current urological training program in Spain. Urology National Specialty Commission.] / El programa actual de la formación en España. Comisión nacional de especialidad.

OBJECTIVES: 44/2003 Law involved the creation of the National Council of Specialties in Health Sciences and the National Commissions of the Specialties in Health Sciences. METHODS: Analysis of the main laws implicated in Specialized Training and the role of the National Specialty Commission. DISCUSSION: 44/2003 Law regulates the training of health professionals and establishes the procedure for the training programs creation by the National Specialty Commission and its later approval and publication in the BOE. Access to specialized training will be carried out with the annual and national MIR exam. The Health Ministry establishes the criteria for educational centers accreditation, and the National Specialty Commission issues a favorable or unfavorable report as advisor about new accreditation requests. 183/2008 RD develops the tutor figure, the formative evaluation through the Resident's Book and how will be like the external rotations. CONCLUSIONS: to understand the Urology's specialty training system we must know the laws that regulate it, being the most important the 44/2003 Law. The National Specialty Commission is an advisory party of the Ministry, whose main function is to elaborate the Urology training program and to establish the evaluation criteria of the specialists in formation.

[Prognostic factors in renal cancer with venous thrombus survival analysis.] / Factores pronósticos en cáncer renal con trombo en vena. Análisis de supervivencia.

OBJECTIVES: To analyze surgery for renal cancer with venous thrombus at different levels, perioperative complications and prognostic factors associated to overall, cancer-specific and disease-free survival. MATERIAL AND METHODS: Retrospective analysis of 42 cases of renal cancer with venous thrombus performed between 2005 and 2015. The level reached by the thrombus was established according to the Mayo Clinic classification. Postoperative complications were staged according to Clavien-Dindo classification. RESULTS: Most frequent in males. Mean age 65.7 years. 16.6% were tumors with level II thrombus. Subcostal approach was performed in 58.9%. Extracorporeal circulation with cardiac arrest and hypothermia was established in 2 patients. Resection of metastatic disease was performed in 3 patients during radical nephrectomy. Reoperation was 2.3% while, perioperative mortality was 4.7%. 30% presented with metastases at diagnosis. Twenty patients progressed at 15.5 months (3-55). Overall survival was 60 months. The cancer-specific mortality was 75%. Disease-free survival was 30% at 55 months. CONCLUSIONS: Surgical treatment of renal cancer with venous thrombus requires a multidisciplinary management. The surgical technique varies according to the level reached by the venous thrombus. Tumor stage is the most important prognostic factor. Thrombus level influences prognosis, with longer survival for patients with tumor thrombus confined to the renal vein (pT3a) in comparison to tumors with thrombus in the atrium (pT3c).

[Small cell carcinoma of the bladder: Our experience]. / CARCINOMA DE CÉLULAS PEQUEÑAS DE VEJIGA.

OBJECTIVES: Small cell carcinoma of the bladder shows low incidence and poor survival; thus, treatment algorithms based on randomized studies are unavailable. The aim of the present study is to review our case series. METHODS: Observational retrospective study of 10 patients diagnosed with small cell carcinoma of the bladder between 2006 and 2013. RESULTS: Mean age was 65.7 years; There was only one female in the cohort. In all cases hematuria was the fist symptom. 4 cases presented high-grade papillary urothelial carcinoma with small cell carcinoma. Radical cystectomy was performed in 40% patients, in combination with chemotherapy, radiotherapy or both. Median survival was 330 days (IC 95%: 40.757- 619.243) and only one patient showed complete response. CONCLUSIONS: Even when small cell carcinoma of the bladder is a low incidence tumor, its prognosis is worse than that of urothelial carcinoma. Although further randomized studies are needed to best define treatment, this study shows that survival at local stages is optimized by neoadjuvant chemotherapy, followed by radical resection, as the literature suggests.

Left ventricular assist devices in patients with end-stage heart failure: suggestion of an alternative treatment based on clinically well-known concepts.

Encouraging results were obtained by using left ventricular assist devices (LVADs) in patients with end-stage heart failure (HF) that exhibits extremely high mortality and who were not candidates for heart transplantation. By using this so-called destination therapy (DT), a substantial percentage of these patients achieved sufficient improvement in cardiac function to permit the explantation of the device. The combination of mechanical and pharmacological therapy increased the frequency and durability of myocardial recovery as compared with other therapeutic approaches. Although cardiac transplantation, LVADs, and cardiac resynchronization therapy have provided a major advance in DT, their limitations stimulate the search for alternative therapies. We discuss the limitations of these 3 treatment options for end-stage HF. Also, we propose and discuss the possible advantages of a new intracorporeal procedure that works continuously as intraaortic balloon counterpulsation without an extracorporeal or intracorporeal computer-controlled mechanism.

Effectiveness and safety of different azacitidine dosage regimens in patients with myelodysplastic syndromes or acute myeloid leukemia.

We investigated the effectiveness and tolerability of azacitidine in patients with World Health Organization-defined myelodysplastic syndromes, or acute myeloid leukemia with 20-30% bone marrow blasts. Patients were treated with azacitidine, with one of three dosage regimens: for 5 days (AZA 5); 7 days including a 2-day break (AZA 5-2-2); or 7 days (AZA 7); all 28-day cycles. Overall response rates were 39.4%, 67.9%, and 51.3%, respectively, and median overall survival (OS) durations were 13.2, 19.1, and 14.9 months. Neutropenia was the most common grade 3-4 adverse event. These results suggest better effectiveness-tolerability profiles for 7-day schedules.

El intervencionismo coronario percutáneo previo no aumenta la mortalidad hospitalaria en cirugía coronaria: análisis de una serie de 63.420 casos / Previous Percutaneous Coronary Intervention Does Not Increase In-Hospital Mortality After Surgical Revascularization: Analysis of 63420 Cases

Introducción En diversas publicaciones de los últimos años se señala una mortalidad hospitalaria mayor de la cirugía de revascularización miocárdica en pacientes con antecedente de intervencionismo coronario percutáneo previo exitoso; por su parte, los modelos de riesgo de mortalidad en cirugía cardíaca publicados hasta la actualidad no han incluido este antecedente como factor de riesgo. Objetivo Analizar si el intervencionismo coronario percutáneo previo es un factor de riesgo de mortalidad hospitalaria en la cirugía de revascularización coronaria. Material y métodos Entre enero de 1997 y diciembre de 2007 se analizaron un total de 78.794 pacientes sometidos a cirugía coronaria, recogidos en la base de datos del Ministerio de Sanidad de España. Tras aplicar los criterios de exclusión, el estudio se realizó sobre un total de 63.420 pacientes, de los que 2.942 (4,6%) tenían intervencionismo coronario percutáneo previo. Las variables continuas se compararon con las pruebas de U de Mann-Whitney o de la t de Student y las variables categóricas, mediante chi cuadrado. Se realizó un análisis de regresión logística univariado y multivariado y un análisis multivariado que incluía un índice de propensión. Resultados El intervencionismo coronario percutáneo previo no fue un predictor independiente de mortalidad hospitalaria en el análisis multivariado (odds ratio 0,88; intervalo de confianza del 95% 0,72-1,07; p = 0,20) ni en el modelo que incluía un índice de propensión (odds ratio 0,9; intervalo de confianza 95% 0,75-1,08; p = 0,27). Conclusión El intervencionismo coronario percutáneo previo parece no ser un factor de riesgo independiente de mortalidad hospitalaria en pacientes con intervención quirúrgica coronaria.

Introduction Recent publications indicate higher in-hospital mortality following myocardial revascularization in patients with previous history of successful percutaneous coronary intervention. Yet, no risk models of surgical mortality have included percutaneous intervention as a risk factor. Objectives The purpose of this study was to analyze whether previous percutaneous coronary intervention is a risk factor of in-hospital mortality in coronary artery bypass grafting. Methods The study included 78794 patients retrieved from the Spanish Ministry of Health database, who underwent coronary artery bypass graft surgery between January 1997 and December 2007. After applying exclusion criteria, 63420 patients were included in the study, 2942 (4.6%) of whom had previously undergone percutaneous coronary intervention. Continuous variables were compared using the Mann-Whitney U test or Student's t test, and categorical variables using the chi-square test. Univariate and multivariate logistic regression analyses and a multivariate analysis including a propensity score were performed. Results Previous percutaneous coronary intervention was not an independent risk factor of in-hospital mortality in the multivariate logistic regression analysis (odds ratio 0.88; 95% confidence interval, 0.72-1.07; p = 0.20) or after adjusting for propensity score (odds ratio 0.9; 95% confidence interval, 0.75-1.08; p = 0.27). Conclusion Previous percutaneous coronary intervention is not an independent risk factor of in-hospital mortality in patients undergoing coronary artery bypass grafting.