Consensus statement of the Spanish Society of Neurology on the treatment of multiple sclerosis and holistic patient management in 2023.

The last consensus statement of the Spanish Society of Neurology's Demyelinating Diseases Study Group on the treatment of multiple sclerosis (MS) was issued in 2016. Although many of the positions taken remain valid, there have been significant changes in the management and treatment of MS, both due to the approval of new drugs with different action mechanisms and due to the evolution of previously fixed concepts. This has enabled new approaches to specific situations such as pregnancy and vaccination, and the inclusion of new variables in clinical decision-making, such as the early use of high-efficacy disease-modifying therapies (DMT), consideration of the patient's perspective, and the use of such novel technologies as remote monitoring. In the light of these changes, this updated consensus statement, developed according to the Delphi method, seeks to reflect the new paradigm in the management of patients with MS, based on the available scientific evidence and the clinical expertise of the participants. The most significant recommendations are that immunomodulatory DMT be started in patients with radiologically isolated syndrome with persistent radiological activity, that patient perspectives be considered, and that the term "lines of therapy" no longer be used in the classification of DMTs (> 90% consensus). Following diagnosis of MS, the first DMT should be selected according to the presence/absence of factors of poor prognosis (whether epidemiological, clinical, radiological, or biomarkers) for the occurrence of new relapses or progression of disability; high-efficacy DMTs may be considered from disease onset.

Mathematical birth of Early Afterdepolarizations in a cardiomyocyte model.

Early Afterdepolarizations (EADs) are abnormal behaviors that can lead to cardiac failure and even cardiac death. In this paper we investigate the occurrence and development of these phenomena in a reduced Luo-Rudy cardiac model. Through a comprehensive dynamical analysis, we map out the distinct patterns observed in the parametric plane, differentiating between normal beats without EADs and pathological beats with EADs. By examining the bifurcation structure of the model, we elucidate the dynamical elements associated with these patterns and their transitions. Using a fast-slow analysis, we explore the emergence and evolution of EADs in the model. Notably, our approach combines the two commonly used fast-slow approaches (1-slow-2-fast and 2-slow-1-fast), and we show how both approaches together provide a more complete understanding of this phenomenon.

[Antimicrobial stewardship program in urinary tract infections due to multiresistant strains in the emergency department]. / Programa de optimización de antibioterapia en infección urinaria por cepas multirresistentes en el servicio de urgencias.

OBJECTIVE: Urinary tract infections (UTI) are a frequent reason for attendance at emergency department (ED). The present study evaluates the impact of a multidisciplinary program for the optimization of antibiotic therapy in patients with UTI caused by multi-drug resistant bacteria treated from the hospital ED. METHODS: Descriptive study of the implementation of a program in which emergency, microbiology and pharmacy departments participated. Antibiotic treatment of the patients who consulted the ED with positive urine cultures caused by multidrug-resistant bacteria was reviewed upon discharge. In those patients with inappropriate treatment, doctors and/or pharmacists of the next level of healthcare or patients in the case of home discharge were contacted. The impact of the program was evaluated based on new visits to the ED at 30 days after discharge, compared with the results obtained from the usual practice three months prior the intervention. RESULTS: During the first year, 2,474 urine cultures of patients with UTI were reviewed, 533 (21.7%) were caused by multidrug-resistant bacteria. Empirical treatment was inappropriate in 287 (53.4%), making treatment modifications in 243 of them. 73 (19.3%) patients returned to the ED 30 days after discharge, being lower than the results obtained in the three months prior intervention (27.9%; p=0.031), without significant differences in new visits associated with UTI. CONCLUSIONS: The implementation of a multidisciplinary program focused on multidrug resistant UTI at discharge form ED correct antibiotic therapy in a large number of patients, being a potentially tool to reduce the number of new ED visits.

Severity classification and influencing variables of the Postintensive Care Syndrome.

OBJECTIVE: The study aims to characterise Postintensive Care Syndrome by classifying the severity of the disease and identifying the variables of influence in two highly complex intensive care units for adults in Colombia. METHODS: A descriptive, cross-sectional, prospective study was carried out to characterise survivors of critical illness using the Healthy Aging Brain Care -Monitor in a sample of 135 patients. Postintensive Care Syndrome severity was classified using Gaussian Mixture Models for clustering, and the most influencing variables were identified through ordinal logistic regression. RESULTS: Clustering based on Gaussian Mixture Models allowed the classification of Postintensive Care Syndrome severity into mild, moderate, and severe classes, with an Akaike Information Criterion of 308 and an area under the curve of 0.80, which indicates a good fit; Thus, the mild class was characterised by a score on the HABC-M Total scale ≤9; the moderate class for a HABC-M Total score ≥10 and ≤42 and the severe class for a HABC-M Total score ≥43. Regarding the most influencing variables, the probability of belonging to the moderate or severe classes was related to male sex (91%), APACHE II score (22.5%), age (13%), intensive care units days of stay (10.6%), the use of sedation, analgesia and neuromuscular blockers. CONCLUSION: Intensive care units survivors were characterised using the Healthy Aging Brain Care-Monitor scale, which made it possible to classify Postintensive Care Syndrome through Gaussian Mixture Models clustering into mild, moderate, and severe and to identify variables that had the major influence on the presentation of Postintensive Care Syndrome.

[Impact of days elapsed from the onset of symptoms to hospitalization in COVID-19 in-hospital mortality: Time matters]. / Impacto de los días transcurridos desde el inicio de los síntomas hasta la hospitalización en la mortalidad hospitalaria por COVID-19: el tiempo importa.

Background: COVID-19 shows different clinical and pathophysiological stages over time. Theeffect of days elapsed from the onset of symptoms (DEOS) to hospitalization on COVID-19prognostic factors remains uncertain. We analyzed the impact on mortality of DEOS to hospital-ization and how other independent prognostic factors perform when taking this time elapsedinto account. Methods: This retrospective, nationwide cohort study, included patients with confirmed COVID-19 from February 20th and May 6th, 2020. The data was collected in a standardized online datacapture registry. Univariate and multivariate COX-regression were performed in the generalcohort and the final multivariate model was subjected to a sensitivity analysis in an earlypresenting (EP; < 5 DEOS) and late presenting (LP; ≥5 DEOS) group. Results: 7915 COVID-19 patients were included in the analysis, 2324 in the EP and 5591 in theLP group. DEOS to hospitalization was an independent prognostic factor of in-hospital mortalityin the multivariate Cox regression model along with other 9 variables. Each DEOS incrementaccounted for a 4.3% mortality risk reduction (HR 0.957; 95% CI 0.93---0.98). Regarding variationsin other mortality predictors in the sensitivity analysis, the Charlson Comorbidity Index onlyremained significant in the EP group while D-dimer only remained significant in the LP group. Conclusion: When caring for COVID-19 patients, DEOS to hospitalization should be consideredas their need for early hospitalization confers a higher risk of mortality. Different prognosticfactors vary over time and should be studied within a fixed timeframe of the disease.

Impact of days elapsed from the onset of symptoms to hospitalization in COVID-19 in-hospital mortality: time matters.

BACKGROUND: COVID-19 shows different clinical and pathophysiological stages over time. The effect of days elapsed from the onset of symptoms (DEOS) to hospitalization on COVID-19 prognostic factors remains uncertain. We analyzed the impact on mortality of DEOS to hospitalization and how other independent prognostic factors perform when taking this time elapsed into account. METHODS: This retrospective, nationwide cohort study, included patients with confirmed COVID-19 from February 20th and May 6th, 2020. The data was collected in a standardized online data capture registry. Univariate and multivariate COX-regression were performed in the general cohort and the final multivariate model was subjected to a sensitivity analysis in an early presenting (EP; <5 DEOS) and late presenting (LP; ≥5 DEOS) group. RESULTS: 7915 COVID-19 patients were included in the analysis, 2324 in the EP and 5591 in the LP group. DEOS to hospitalization was an independent prognostic factor of in-hospital mortality in the multivariate Cox regression model along with other 9 variables. Each DEOS increment accounted for a 4.3% mortality risk reduction (HR 0.957; 95% CI 0.93-0.98). Regarding variations in other mortality predictors in the sensitivity analysis, the Charlson Comorbidity Index only remained significant in the EP group while D-dimer only remained significant in the LP group. CONCLUSION: When caring for COVID-19 patients, DEOS to hospitalization should be considered as their need for early hospitalization confers a higher risk of mortality. Different prognostic factors vary over time and should be studied within a fixed timeframe of the disease.

Five years' experience of the clinical exome sequencing in a Spanish single center.

Nowadays, exome sequencing is a robust and cost-efficient genetic diagnostic tool already implemented in many clinical laboratories. Despite it has undoubtedly improved our diagnostic capacity and has allowed the discovery of many new Mendelian-disease genes, it only provides a molecular diagnosis in up to 25-30% of cases. Here, we comprehensively evaluate the results of a large sample set of 4974 clinical exomes performed in our laboratory over a period of 5 years, showing a global diagnostic rate of 24.62% (1391/4974). For the evaluation we establish different groups of diseases and demonstrate how the diagnostic rate is not only dependent on the analyzed group of diseases (43.12% in ophthalmological cases vs 16.61% in neurological cases) but on the specific disorder (47.49% in retinal dystrophies vs 24.02% in optic atrophy; 18.88% in neuropathies/paraparesias vs 11.43% in dementias). We also detail the most frequent mutated genes within each group of disorders and discuss, on our experience, further investigations and directions needed for the benefit of patients.

Dual-energy CT: Technical considerations and clinical applications.

Although dual-energy CT was initially described by Hounsfield in 1973, it remains underused in clinical practice. It is therefore important to emphasize the clinical benefits and limitations of this technique. Iodine mapping makes it possible to quantify the uptake of iodine, which is very important in characterizing tumors, lung perfusion, pulmonary nodules, and the tumor response to new treatments. Dual-energy CT also makes it possible to obtain virtual single-energy images and virtual images without iodinated contrast or without calcium, as well as to separate materials such as uric acid or fat and to elaborate hepatic iron overload maps. In this article, we review some of the clinical benefits and technical limitations to improve understanding of dual-energy CT and expand its use in clinical practice.

The second Mexican consensus on hepatocellular carcinoma. Part II: Treatment.

Hepatocellular carcinoma (HCC) is more frequently manifesting as one of the main complications of cirrhosis of the liver, its principal risk factor. There have been modifications in its incidence over the past decade, related to an epidemiologic transition in the etiology of cirrhosis, with a decrease in the prevalence of hepatitis C and an increase in nonalcoholic fatty liver disease (NAFLD) as a cause, as well as the development of HCC in the non-cirrhotic liver due to NAFLD. Genetic markers associated with the disease have been identified, and surveillance and diagnosis have improved. Regarding treatment, surgical techniques, in both resection and transplantation, have advanced and radiologic techniques, at the curative stage of the disease, have enhanced survival in those patients. And finally, there have been radical changes in the systemic approach, with much more optimistic expectations, when compared with the options available a decade ago. Therefore, the Asociación Mexicana de Hepatología decided to carry out the Second Mexican Consensus on Hepatocellular Carcinoma, which is an updated review of the available national and international evidence on the epidemiology, risk factors, surveillance, diagnosis, and treatment of the disease, to offer the Mexican physician current information on the different topics regarding hepatocellular carcinoma. In this second part of the document, the topics related to the treatment of HCC are presented.

Operative safety of orthotopic liver transplant in patients with prior transjugular intrahepatic portosystemic shunts: A 20-year experience.

INTRODUCTION AND AIMS: Orthotopic liver transplant (OLT) is the definitive treatment of most types of liver failure. Transjugular intrahepatic portosystemic shunt (TIPS) and portocaval shunt placement procedures reduce the systemic vascular complications of portal hypertension. TIPS placement remains a "bridge" therapy that enables treatment of refractory symptoms until transplantation becomes available. The aim of the present study was to describe the operative impact of TIPS prior to OLT. MATERIALS AND METHODS: A retrospective review was conducted on patients that underwent liver transplant at the Hospital San José within the timeframe of 1999 and February 2020. RESULTS: We reviewed a total of 92 patients with OLT. Sixty-six patients were male and 26 were female, with a mean age of 52 years. Nine (9.8%) of the 92 patients had a TIPS, before the OLT. Preoperative Child-Pugh class, MELD score, and sodium and platelet levels were similar between groups. We found no difference in the means of intensive care unit stay, operative time, or blood transfusions for liver transplant, with or without previous TIPS. There was no significant difference between groups regarding vascular and biliary complication rates or the need for early intervention. The overall one-year mortality rate in the TIPS group was 11%. CONCLUSIONS: TIPS is an appropriate therapeutic bridge towards liver transplant. We found no greater operative or postoperative complications in patients with TIPS before OLT, when compared with OLT patients without TIPS. The need for transfusion, operative time, and ICU stay were similar in both groups.

The second Mexican consensus on hepatocellular carcinoma. Part I: Epidemiology and diagnosis.

Hepatocellular carcinoma (HCC) is more frequently manifesting as one of the main complications of cirrhosis of the liver, its principal risk factor. There have been modifications in its incidence over the past decade, related to an epidemiologic transition in the etiology of cirrhosis, with a decrease in the prevalence of hepatitis C and an increase in nonalcoholic fatty liver disease (NAFLD) as a cause, as well as the development of HCC in the non-cirrhotic liver due to NAFLD. Genetic markers associated with the disease have been identified, and surveillance and diagnosis have improved. Regarding treatment, surgical techniques, in both resection and transplantation, have advanced and radiologic techniques, at the curative stage of the disease, have enhanced survival in those patients. And finally, there have been radical changes in the systemic approach, with much more optimistic expectations, when compared with the options available a decade ago. Therefore, the Asociación Mexicana de Hepatología decided to carry out the Second Mexican Consensus on Hepatocellular Carcinoma, which is an updated review of the available national and international evidence on the epidemiology, risk factors, surveillance, diagnosis, and treatment of the disease, to offer the Mexican physician current information on the different topics regarding hepatocellular carcinoma. In this first part of the document, the topics related to epidemiology and diagnosis are presented.

Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy.

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

A 20-year experience in cadaveric pediatric en bloc kidney transplantation in adult recipients.

BACKGROUND AND OBJECTIVES: En bloc kidney transplantation (EBKT) from pediatric donors into adult recipients increases the donor pool. However, this surgical procedure is not widely performed in many transplant centers. To evaluate the long-term outcomes of EBKT from pediatric donors into adult recipients in a single center. MATERIAL AND METHODS: Retrospective analysis of 42 patients who received pediatric cadaveric EBKT in our center since 1999. Median follow-up period was 73 months (5-233) in which renal function tests were taken and complications registered. RESULTS: We have performed 42 EBKT from pediatric donors into adult recipients in our center. The recipients' age was 44.1 ± 11.8 years. Pediatric donors were 22.4 ± 14.7 months old and weighted 11.3 ± 3.6 kg. Cold ischemia time was 15.7 ± 4.5 h. During a median follow-up of 73 months, 35 patients (83.3%) had graft survival with excellent function (first-year serum creatinine levels of 0.99 ± 0.25 mg/dl). There were seven graft losses (16.7%) in the immediate postoperative period (four cases of vascular thrombosis, one anastomosis dehiscence and two cortical necrosis). CONCLUSIONS: The pediatric en bloc renal graft transplantation into adults is a safe technique with excellent medium- to long-term functional performance. The vast majority of significant complications leading to graft loss were reported in the immediate postoperative period. A good selection of donors and recipients as well as an adequate surgical technique are essential to minimize the occurrence of adverse events.

Potential of High-Resolution Mass Spectrometry for the Detection of Drugs and Metabolites in Hair: Methoxetamine in a Real Forensic Case.

The analysis of drugs of abuse in hair and other biological matrices of forensic interest requires great selectivity and sensitivity. This is done traditionally through target analysis, with one or more analytical methods, or with different and specific preanalytical phases, and complex procedures performed by the toxicological laboratories, and there is no exception with ketamine-like compounds, such as methoxetamine, a new psychoactive substance whose use has increased in the last decades, and continues to grow quickly year by year. More validated methods of analysis are needed to detect these substances in low concentrations selectively. Reanalyzing the samples of a former case of a polydrug consumer accused of a crime against public health in Spain, five metabolites of methoxetamine (normethoxetamine, O-desmethylmethoxetamine, dehydromethoxetamine, dihydronormethoxetamine and hydroxynormethoxetamine) were tentatively detected using a high-resolution technique, that is, liquid chromatography coupled to high-resolution mass spectrometry (LC-HR-MS-MS). The highest analytical selectivity of LC-HR-MS-MS method together a universal and simpler pretreatment stages has demonstrated to allow faster analysis and more sensitivity than the one performed traditionally at the INTCF laboratories, which was gas chromatography coupled to mass spectrometry.

Effectiveness and patient satisfaction with office hysteroscopic polypectomy in patients with symptomatic endometrial polyps.

Background: Endometrial polyps are a common cause of abnormal uterine bleeding. In-office hysteroscopic management is frequently performed to treat this frequently encountered pathology. Objectives: To evaluate the long-term outcome and patients' satisfaction with office hysteroscopic polypectomy in patients with symptomatic endometrial polyps. Materials and Methods: Retrospective longitudinal observational study of all hysteroscopic polypectomies performed at d'Igualada University Hospital (Barcelona, Spain) between May 2016 and December 2018. The medical records were reviewed, and a telephone interview was conducted with all the patients diagnosed with symptomatic endometrial polyps who underwent outpatient hysteroscopic polypectomy, with the purpose of evaluating the post-procedure symptomatology and satisfaction with the procedure. Main outcomes and results: A total of 848 outpatient hysteroscopies were performed, 379 of which were polypectomies. Of those, 163 procedures were performed in symptomatic patients and were included in the final analysis. The most common symptom among premenopausal patients was abnormal uterine bleeding (84.85%) and in postmenopausal women, postmenopausal bleeding (95.3%). After the procedure, the symptoms resolved or decreased considerably in 66.7% of premenopausal and 93.7% of postmenopausal patients. Additionally, 87.1% of the patients were very satisfied with the procedure. Conclusion: Office hysteroscopic polypectomy is an effective treatment for endometrial polyps with high patient satisfaction reported following the procedure.

First insight into plastics ingestion by fish in the Gulf of California, Mexico.

Plastic particle occurrence in the digestive tracts of fishes from a tropical estuarine system in the Gulf of California was investigated. A total of 1095 fish were analysed, representing 15 species. In total 1384 particles of plastic debris were recovered from the gastrointestinal tracts of 552 specimens belonging to 13 species, and all consisted of threads, the majority of which were small microplastics (0.23 to 1.89), followed by large microplastics (2.07 to 4.49), and few mesoplastics (5.4 to 19.86). Plastic particles were identified using ATR-FTIR spectroscopy. The mean frequency of occurrence of plastics in the gastrointestinal tracts of fishes from this system was 50.5%, which is higher than frequencies reported in similar systems in other areas. The polymers identified by ATR-FTIR were polyamide (51.2%), polyethylene (36.6%), polypropylene (7.3%), and polyacrylic (4.9%). These results show the first evidence of plastic contamination for estuarine biota in the Gulf of California.

Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy. / Guía anestésico-quirúrgica en el tratamiento de la cirugía de aorta ascendente y del arco aórtico. Documento de consenso de la Sociedad Española de Cirugía Cardiovascular y Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor.

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

Sanger sequencing is no longer always necessary based on a single-center validation of 1109 NGS variants in 825 clinical exomes.

Despite the improved accuracy of next-generation sequencing (NGS), it is widely accepted that variants need to be validated using Sanger sequencing before reporting. Validation of all NGS variants considerably increases the turnaround time and costs of clinical diagnosis. We comprehensively assessed this need in 1109 variants from 825 clinical exomes, the largest sample set to date assessed using Illumina chemistry reported. With a concordance of 100%, we conclude that Sanger sequencing can be very useful as an internal quality control, but not so much as a verification method for high-quality single-nucleotide and small insertion/deletions variants. Laboratories might validate and establish their own thresholds before discontinuing Sanger confirmation studies. We also expand and validate 23 copy number variations detected by exome sequencing in 20 samples, observing a concordance of 95.65% (22/23).

RETRACTED: Anesthesic and surgical guideline for the treatment of the thoraco-abdominal aorta. Consensus Document of the Spanish Societies of Anesthesia and Cardiovascular Surgery. / Guía anestésico-quirúrgica en el tratamiento de la patología de aorta toracoabdominal. Documento de Consenso de la Sociedad Española de Cirugía Cardiovascular Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor.

Este artículo ha sido retirado por indicación del Editor Jefe de la revista, después de constatar que parte de su contenido había sido plagiado, sin mencionar la fuente original: European Heart Journal (2014) 35, 2873 926.: https://academic.oup.com/eurheartj/article/35/41/2873/407693#89325738 El autor de correspondencia ha sido informado de la decisión y está de acuerdo con la retirada del artículo. El Comité Editorial lamenta las molestias que esta decisión pueda ocasionar. Puede consultar la política de Elsevier sobre la retirada de artículos en https://www.elsevier.com/about/our-business/policies/article-withdrawal