Efficacy and safety of adjustable suture in horizontal strabismus: Comparative study of children versus adults.

OBJECTIVE: Adjustable suture procedures allow addressing the unpredictability of some postoperative results in strabismus surgery. The purpose of the study was to compare the effectiveness of adjustable and non-adjustable suture in the treatment of horizontal strabismus in children and adults. METHODS: Prospective study including patients undergoing strabismus surgery to correct horizontal strabismus with fixed hanging suture (non-adjustable suture group) and adjustable suture. Visual acuity, amblyopia, deviation, oblique muscle involvement, previous surgeries, nystagmus, need for adjustment, and complications were recorded. The variables were recorded in the immediate postoperative period, at one week and at 3 and 6 months. RESULTS: 186 patients were included: 157 (84.4%) with adjustable suture and 29 (15.6%) with non-adjustable suture, of which 119 were children and 67 were adults. Postoperatively, 19 children (16.0%) and 19 adults (28.4%) required adjustment (p = 0.044). Of 157 patients with adjustable suture, it was adjusted in 20% (32/157). Success after adjustment was higher for adjustable suture (91.72% vs 79.31%; p = 0.043) and remained for 6 months (p < 0.05). Previous surgery (p = 0.004) and exotropia (p = 0.018) correlated with the need for adjustment. CONCLUSIONS: 20% of patients with horizontal strabismus can benefit from a postoperative adjustment to improve the surgical result. The adjustable suture was shown to be superior to the fixed hanging suture and is an excellent surgical option, both in children and adults.

Management of liver transplantation waiting list for decompensated cirrhosis in a Spanish tertiary hospital: differences between hepatitis C virus recipients and other etiologies.

BACKGROUND: Decompensated cirrhosis due to hepatitis C virus (HCV) is one of the main indications for liver transplantation (LT) in Spain. Recurrence of HCV after LT is the main cause of graft loss and death in HCV-positive recipients. Advanced donor age determines a more aggressive recurrence of HCV and a shorter survival. In this setting, in our liver unit, grafts from younger donors are allocated to HCV-positive recipients. The aim of this study was a comparative analysis of allocation of grafts in HCV-positive recipients versus other etiologies and the impact on waiting list time, Model for End-Stage Liver Disease (MELD) score progression until LT, need of admission in a hospital, survival until LT. METHODS: This was a retrospective study from the cohort of patients included in the waiting list for LT owing to decompensated cirrhosis in the Hospital Gregorio Marañón from January 2008 to June 2013. RESULTS: A total of 91 patients were included; 63 patients (69.23%) received LT; 19 (20.88%) retired from the waiting list: 6 because of improvement, 11 (12.08%) because of death. In both groups, the age of recipients was similar (HCV 52 y vs other 53 y; P = .549). HCV patients were included in the waiting list with lower MELD score than other etiologies (HCV 16.1 vs other 19.4; P = .010); nevertheless, MELD score was similar at the time of LT in both groups (HCV 18.9 vs other 19.4; P = .675). Time on waiting list was significantly longer in HCV patients (198 d vs 86 d; P = .002) and they were admitted in hospital more days (30 d vs 12 d; P = .03). Donor age in the HCV group was significantly lower (64.3 y vs 54.7 y; P = .006). The intention-to-treat survival analysis did not show differences between the groups (log rank = 0.504). CONCLUSIONS: HCV patients with decompensated cirrhosis receive grafts from younger donors. HCV patients remain waiting longer for an optimal organ and suffer MELD deterioration and more days admitted in hospital. These differences in allocation of grafts did not affect final survival. In our experience, designating younger organs to HCV-positive patients does not penalize neither HCV recipients nor recipients with other etiologies.

[Analysis of oxidative stress in exhaled breath condensate from patients with severe pulmonary infections]. / Estrés oxidativo en el condensado exhalado de pacientes con infección pulmonar grave.

OBJECTIVE: Oxidative stress is an intrinsic part of the chain of events leading to inflammation of the airways caused by bacterial infection. The aim of this study was to determine whether analysis of exhaled breath condensate from patients with severe lung infections reveals changes in the redox state at the airway surface. PATIENTS AND METHODS: The study included a total of 48 subjects divided into 4 groups: individuals without respiratory disease (n=14), patients with multilobar pneumonia (n=13), patients who had chronic obstructive pulmonary disease with superinfection (n=14), and mechanically ventilated patients with severe pneumonia (n=7). A sample of exhaled breath condensate was obtained within the first 72 hours of hospital admission and the concentrations of nitrite, nitrate, 8-isoprostane, and myeloperoxidase (MPO) were determined. RESULTS: Significant differences in the concentrations of nitrite, 8-isoprostane, and MPO were observed between patients and individuals without respiratory disease but no differences were found between the 3 patient groups. The concentration of MPO was correlated with the concentrations of 8-isoprostane and nitrate, which were normalized to the nitrite concentration. CONCLUSIONS: Analysis of the concentrations of 8-isoprostane and MPO in exhaled breath condensate allows assessment of oxidative stress in the airways of patients with severe lung infections.

Tumoral response factors after radiofrequency ablation of hepatocellular carcinoma in cirrhotic liver.

OBJECTIVE: Hepatocellular carcinoma (HCC) ablation by radiofrequency (RFA) is a novel technique with a great variety of methods whose efficacy and predictive factors have not been completely studied. Some of the main predictive factors in this type of treatment are analyzed in the present study. PATIENTS AND METHODS: Ninety-three patients with hepatocellular carcinoma over cirrhosis, and with no indication for surgical resection were treated by RFA. Two different types of electrodes were used for RFA (refrigerated-"Cool-Tip" and perfusion with saline solution, the approach was percutaneous, by laparoscopy or laparotomy. RESULTS: Overall survival at 1, 2 and 3 years was 88, 81, and 76%, with a free-disease survival (FDS) of 66, 31 and 17%, respectively. For tumors less than 3 cm, FDS at 1,2 and 3 years was 74, 44 and 30%, while for more than 3 cm in size FDS was 55, 12 and 0% (p = 0.02). FDS for HCC with one nodule was 70, 36 and 22%, and for more than one nodule it decreased to 50, 17 and 0% at 1, 2 and 3 years, respectively (p = 0.07). Surprisingly, the method employed for RFA has a main influence in FDS, with 0% at 3 years for perfusion electrodes and 26% for cool-tip electrodes at the same period. CONCLUSIONS: In this series, overall survival at three years was relatively high; however, tumoral size, number of nodules and RFS method were independent variables associated with disease-free survival.

[Genetic susceptibility to the development of acute alcoholic hepatitis: role of genetic mutations in dehydrogenase alcohol, aldehyde dehydrogenase and cytochrome P450 2E1]. / Susceptibilidad genética al desarrollo de hepatitis alcohólica aguda: papel de las mutaciones genéticas en alcohol deshidrogenasa, aldehído deshidrogenasa y citocromo P450 2E1.

OBJECTIVE: Analyze the frequencies of genetic mutation in alcohol dehydrogenase (ADH), aldehyde dehydrogenase (ALDH) and cytochrome P450 2E1 (CYP2E1) and establish their possible association with the development of acute alcoholic hepatitis (AAH). METHODOLOGY: Case-control study in a total of 85 Spanish patients. We distinguish three groups (one case group and two control groups) based on hepatic histological lesion and alcohol consumption: controls (group 1: teetotalers; group 2: drinkers without AAH; cases: group 3: drinkers with AAH). Case diagnosis was established based on the presence of polymorphonuclear leukocyte infiltrate in histological study. We analyzed the presence of the genetic mutations R47H and R369C (ADH2), E487K (ALDH2) and mutation Rsa I of CYP2E1 (allele c2) by polymerase chain reaction (PCR) and capillary electrophoresis. RESULTS: The allele c2 of CYP2E1 was found in 10%, 16% and 50% of the groups 1, 2 and 3 patients, respectively. Presence of the mutation Rsa I showed influence on the development of AAH (odds ratio [OR]: 3.63; confidence interval (95% [CI]: 0.88-15.02). CONCLUSIONS: The data suggest a possible association between the presence of the Rsa I of CYP2E1 and the development of AAH in patients with chronic alcohol consumption.

[Artificial liver support systems: update on albumin dialysis (MARS)]. / Sistemas de soporte hepático artificial: estado actual del tratamiento con diálisis de albúmina (MARS).

Mortality among patients with liver insufficiency continues to be unacceptably high. The prognosis of patients with acute episodes of chronic liver insufficiency is almost as poor as that of patients with acute liver failure. Therefore, systems that support liver function, either until liver transplantation can be performed or until resolution of the situation before acute injury occurs, are essential. Albumin dialysis is a system of artificial liver support that allows detoxification of albumin-related and hydrosoluble substances, thus maintaining the patient's homeostasis. Current clinical experience of this therapy is still limited, although beneficial effects on clinical, laboratory and hemodynamic parameters have been demonstrated. Multicenter, controlled trials to evaluate the effect of this therapy on survival in distinct diseases are needed.

Donors with positive blood culture: could they transmit infections to the recipients?

A retrospective analysis of data from January 1996 to June 2004 was performed to evaluate the transmission of bacterial infections from organ donors to recipients. Donors were classified according to blood culture results: group 1 with negative blood culture (n = 216), and group 2 with positive blood cultures (n = 52). The age, cause of death, temperature, leukocytes, and number of organs procured were similar in both groups. Donors of group 2 had significantly more days in the intensive care unit (ICU): group 1 (3.14 +/- 3) versus group 2 (4.39 +/- 3.38 days P = .038). Fifty-one percent of group 1 and 52% of group 2 received antibiotic treatment, in most cases because of the suspected presence of a respiratory infection. In 22 donors the organisms that yielded in the blood culture were considered potentially pathogenic/contaminants (subgroup 2A) and in 30 donors the organisms were considered pathogenic (subgroup 2B). The demographic profiles of these two subgroups were similar. During the first month after transplantation, kidney and liver recipients were closely monitored. Recipients received wide-spectrum antimicrobial prophylaxis. Ten of 61 renal recipients developed infectious diseases. In nine cases (four in subgroup 2A and five in subgroup 2B) there were urinary infections. One recipient of subgroup 2B developed prostatitis. Six of 34 hepatic recipients developed infectious diseases. Four of the six cases (four in group 2A and five in group 2B) developed catheter infections and two cases of peritoneal infections. We could not find any case where a bacterial blood isolate from a donor matched a positive culture in the corresponding recipient. A longer stay of a donor in the ICU resulted in the more pronounced growth of organisms in blood cultures, as expected. In our experience, organs obtained from a donor with a positive blood culture may be transplanted safely, probably due to the low virulence of the organisms as well as the polymicrobial therapy routinely given to the recipients.

[Liver abscess and Crohn' disease. Report of 3 cases]. / Absceso hepático y enfermedad de Crohn. Presentación de 3 casos.

Liver abscess is a rare complication of Crohn's disease. Its prevalence and mortality are higher in patients with Crohn's disease than in the general population. Owing to its nonspecific clinical presentation, which may be mistaken for reactivation of Crohn's disease or be masked by simultaneous steroid therapy, a high index of suspicion is required for an early diagnosis and prompt treatment. We report 3 cases of Crohn's disease complicated with liver abscess in which the only common features were the absence of clinical or even endoscopic activity of Crohn's disease at diagnosis and the presence of an anastomotic leak due to right ileocolectomy in the previous year. In all patients, outcome was satisfactory with antibiotic therapy and percutaneous catheter drainage.

Importance of tumoral markers in donors: study of prostate-specific antigen.

UNLABELLED: We established a protocol to determine the serum prostate-specific antigen (PSA) in male donors of 50 years or older, and to histologically examine the prostate glands. From January 1997 to December 2002 we analysed serum PSA in 51 cases, of which it was normal in 34 and high in 17. Prostate glands were examined histologically in 13 of the high PSA cases. Donors were classified according to the PSA level and histology: donors with high PSA values and adenocarcinoma or high-grade PIN (group A, n=6); donors with elevated PSA but no malignancy (group B, n=7); and donors with normal PSA (group C, n=34). The ages, days in hospital, and causes of death were similar among the 3 groups. The levels of PSA were significantly higher among group A than group B or group C, but were similar between group B and C. The list of transplanted organs is as follows: 5 organs of group A; 8 organs of group B; and 59 organs of group C. CONCLUSIONS: High PSA levels seem show 2 patterns: (1) small increases of PSA related to donors with no prostate cancer, and (2) high levels of PSA related to the presence of prostate cancer, as is the case in the general population. The incidence of prostate cancer in overall male donors was 3.1%. Due to this high incidence, we believe it is important to determine PSA levels to diagnose prostate cancer in older donors. A separate consideration is what to do with the organs of those donors.

[Indications and therapeutic possibilities of albumin dialysis (MARS)].

Despite remarkable medical advances during the last few years, liver failure--both acute and chronic--still results in high mortality. Since liver transplant programs were developed to improve survival in numerous hepatic end-stage disorders, fewer than 15% of patients with liver failure do actually receive a transplantation, be it because of the presence of procedural contraindications (toxic habits, age, concurrent disease), or of clinical conditions that may render surgery more difficult or worsen transplant prognosis. All these circumstances encouraged the development of alternative procedures to increase liver graft availability, as is the case of liver partition techniques and living-donor transplantation. On the other hand, organ scarcity for transplantation during the 1960s encouraged the parallel development of liver support systems in an attempt to reduce mortality and to improve patient survival while waiting for a transplant. Such systems attempt to replace a number of synthesis and detoxification functions for the damaged liver parenchyma. During the past few years both bioartificial systems--also referred to as "bioartificial livers"--based on bioreactors containing functionally active living hepatocytes, and extracorporeal liver detoxification systems have been developed. The latter type includes the so-called MARS (molecular adsorbent recirculating system) system, which combines albumin-bound molecule clearance and novel dialysis membrane biocompatibility.

Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial.

BACKGROUND: Non-invasive pressure support ventilation (NIPSV) is an effective treatment for acute respiratory failure in patients with chronic obstructive pulmonary disease. We assessed the efficacy of this therapy in acute cardiogenic pulmonary oedema in a randomised comparison with conventional oxygen therapy. METHODS: 40 patients were randomly assigned conventional oxygen therapy or NIPSV supplied by a standard ventilator through a face mask, with adjustment of tidal volume and pressure support in addition to a positive end-expiratory pressure of 5 cm water. Physiological measurements were obtained in the first 2 h and at 3 h, 4 h, and 10 h. The main endpoints were intubation rate and resolution time. Analyses were by intention to treat. FINDINGS: Three patients were withdrawn on the basis of clinical and chest radiography results. Endotracheal intubation was required in one (5%) of 19 patients assigned NIPSV and in six (33%) of 18 assigned conventional oxygen therapy (p=0.037). Resolution time (defined as a clinical improvement with oxygen saturation of 96% or more and respiratory rate less than 30 breaths/min) was significantly shorter in the NIPSV group (median 30 [IQR 15-53] vs 105 [50-230] min, p=0.002). NIPSV led to a rapid improvement in oxygenation in the first 2 h. There were no differences in hospital length of stay or mortality. INTERPRETATION: In this study of acute cardiogenic pulmonary oedema, NIPSV was superior to conventional oxygen therapy. Further studies should compare NIPSV with continuous positive airway pressure.

Transjugular intrahepatic portosystemic shunt with the Strecker stent for control of refractory acute and chronic variceal bleeding.

BACKGROUND: We wanted to assess prospectively the safety, efficacy, and applicability of transjugular intrahepatic portosystemic shunt (TIPS) with the Strecker stent, focusing mainly on clinical and hemodynamic medium- and long-term follow-up. METHODS: Fifty-two patients reached an indication to perform a TIPS, in an emergency or after refractory variceal bleeding. It was completed in 50 of them. All presented with cirrhosis (Child C = 15, B = 23, A = 12). The prosthesis was a Strecker stent. During the follow-up, clinical, biochemical, endoscopic, ultrasound, and pressure measurement studies were performed at 1, 3, 6, 12 months. Mean follow-up was 13.5 + or - 7.8 months. RESULTS: Portal pressure decreased from 32.3 + or - 8.1 (mean + or - standard deviation) to 22.3 + or - 6.7 mm Hg and portocaval gradient from 21 +/- 5.2 to 8.7 +/- 3.9 mm Hg (average, 56 + or - 16%). Shunt dysfunction was diagnosed when the portocaval gradient was >12 mm Hg (20 patients). Eleven patients (22%) presented with variceal rebleeding because of shunt dysfunction. The probability of remaining free of bleeding was 78%, 74%, and 68% at 6, 12, and 24 months, respectively. Actuarial survival rate was 91% and 86% after 12 and 18 months, respectively. CONCLUSION: TIPS with the Strecker stent is a safe alternative for variceal bleeding. Shunt dysfunction is frequent and increases the rebleeding rate, requiring a close follow-up with pressure measurements. Randomized trials comparing stents and other alternatives are needed to fully address the role of this procedure.