Primary aldosteronism: Practical recommendations for treatment and follow-up.

Primary aldosteronism (PA) is the most common cause of secondary arterial hypertension. For unilateral cases, surgery offers the possibility of cure, with unilateral adrenalectomy being the treatment of choice, whereas bilateral forms of PA are treated mainly with mineralocorticoid receptor antagonists (MRA). The goals of treatment for PA due to either unilateral or bilateral adrenal disease include reversal of the adverse cardiovascular effects of hyperaldosteronism, normalization of serum potassium in patients with hypokalemia, and normalization of blood pressure. The Primary Aldosteronism Surgery Outcome group (PASO) published a study defining clinical and biochemical outcomes based on blood pressure and correction of hypokalemia and aldosterone to renin ratio (ARR) levels for patients undergoing total unilateral adrenalectomy for unilateral PA. In this review, we provide several practical recommendations for the medical and surgical management and follow-up of patients with PA.

Lung ultrasound and postoperative follow-up of congenital diaphragmatic hernia.

Lung ultrasound (LU) has emerged as a valuable tool for assessing pulmonary aeration noninvasively, rapidly, and reliably in different neonatal conditions. However, its role in the preoperative and postoperative evaluation in congenital diaphragmatic hernia (CDH) is still poorly analyzed. We present a cohort of 8 patients diagnosed with CDH who underwent lung ultrasound examinations at various time points before and after surgical correction. The lung ultrasound patterns were compared between two groups: mechanical ventilation ≤ 7 days (MV ≤ 7) and mechanical ventilation > 7 days (MV > 7). The ultrasound findings were also compared to CT scans and chest X-ray images to assess its diagnostic capacity for identifying postoperative complications: pneumothorax, pleural effusion, and pneumonia. Group MV ≤ 7 exhibited a normal pattern even at 48 h postsurgery, while group MV > 7 presented interstitial or alveolointerstitial pattern in both lungs for prolonged periods (2-3 weeks). Furthermore, contralateral LU pattern may be predictive of respiratory evolution.  Conclusion: Lung ultrasound is a valuable tool for evaluating the progressive reaeration of the lung following surgical correction in CDH patients. It demonstrates the ability to diagnose common postoperative complications without the need for radiation exposure while offering the advantages of quick and serial assessments. These findings highlight the potential of lung ultrasound as an effective alternative to conventional imaging methods in the management of CDH. What is Known: • Lung ultrasound evaluates lung aeration and predicts respiratory outcomes in neonatal patients. What is New: • Lung ultrasound is useful in the postsurgical management of congenital diaphragmatic hernia patients, detecting reaeration and respiratory complications.

Prevalence, risk factors and evolution of diabetes mellitus after treatment in primary aldosteronism. Results from the SPAIN-ALDO registry.

PURPOSE: To evaluate the prevalence, risk factors and evolution of diabetes mellitus (DM) after targeted treatment in patients with primary aldosteronism (PA). METHODS: A retrospective multicenter study of PA patients in follow-up at 27 Spanish tertiary hospitals (SPAIN-ALDO Register). RESULTS: Overall, 646 patients with PA were included. At diagnosis, 21.2% (n = 137) had DM and 67% of them had HbA1c levels < 7%. In multivariate analysis, family history of DM (OR 4.00 [1.68-9.53]), the coexistence of dyslipidemia (OR 3.57 [1.51-8.43]) and advanced age (OR 1.04 per year of increase [1.00-1.09]) were identified as independent predictive factors of DM. Diabetic patients were on beta blockers (46.7% (n = 64) vs. 27.5% (n = 140), P < 0.001) and diuretics (51.1% (n = 70) vs. 33.2% (n = 169), p < 0.001) more frequently than non-diabetics. After a median follow-up of 22 months [IQR 7.5-63.0], 6.9% of patients developed DM, with no difference between those undergoing adrenalectomy and those treated medically (HR 1.07 [0.49-2.36], p = 0.866). There was also no significant difference in the evolution of glycemic control between DM patients who underwent surgery and those medically treated (p > 0.05). CONCLUSION: DM affects about one quarter of patients with PA and the risk factors for its development are common to those of the general population. Medical and surgical treatment provides similar benefit in glycemic control in patients with PA and DM.

Surgical and postsurgical management of abdominal paragangliomas and pheochromocytomas.

PURPOSE: To describe our current protocol for surgical and postsurgical management of abdominal paragangliomas (PGLs) and pheochromocytomas, with a special focus on multidisciplinary management in centres with experience. METHODS: The physicians involved in the management of patients with abdominal PGLs and pheochromocytomas of our hospital reviewed systematically current knowledge on the surgical management of abdominal PGLs and pheochromocytomas. RESULTS: Currently, surgery is considered the treatment of choice for abdominal PGLs and pheochromocytomas. The choice of surgical approach is determined based on the location of the lesion, size, patient́s body habitus and the likelihood of malignancy. Laparoscopic surgery is usually considered the gold standard approach for pheochromocytomas, but open access should be considered in invasive and/or potentially malignant tumours >8-10 cm and for abdominal PGLs. Postsurgical management of pheochromocytomas and PGLs includes close hemodynamic monitoring and treatment of postsurgical complications, the pathological study of the surgical specimen, reassessment of hormonal and/or radiological status and planning of follow-up based on the risk of recurrence and malignancy. CONCLUSION: Surgery represents the treatment of choice of most abdominal PGLs and pheochromocytomas. Optimal postsurgical evaluation, including hemodynamic, pathological, hormonal, and radiological evaluation, should be performed by a multidisciplinary team specializing in PGL/pheochromocytoma management.

Prevalence and phenotype of primary bilateral macronodular adrenal hyperplasia with autonomous cortisol secretion: a study of 98 patients.

AIM: This study evaluated prevalence of primary bilateral macronodular adrenal hyperplasia (PBMAH). It also analyzed the differential phenotype of patients with PBMAH compared to other bilateral adrenal lesions that do not meet the definition of PBMAH. METHODS: We reviewed the medical records of 732 patients diagnosed with an adrenal incidentaloma at our center. Ninety-eight patients with subclinical hypercortisolism were included in the analysis. We defined PBMAH as the presence of plasma cortisol > 1.8 µg/dL after an over-night 1-mg dexamethasone test, bilateral adrenal hyperplasia, and bilateral adrenal nodules > 1 cm. RESULTS: A total of 31 patients had PBMAH. Patients with PBMAH showed greater prevalence of autonomous cortisol secretion (plasma cortisol > 5.0 µg/dL after an overnight 1-mg dexamethasone test) than patients without PBMAH (OR 4.1, 95%CI 1.38-12.09, p = 0.010). Tumor size and total adenomatous mass were significantly greater in patients with PBMAH compared to patients without PBMAH (30.2 ±â€¯12.16 vs. 24.3 ±â€¯8.47 mm, p = 0.010 and 53.9 ±â€¯20.8 vs. 43.3 ±â€¯14.62 mm, p = 0.023), respectively. A greater proportion of patients with PBMAH had diabetes compared to patients without PBMAH (45.2% vs. 25.4%, p = 0.05). CONCLUSION: PBMAH is present in one-third of patients with adrenal incidentaloma and subclinical hypercortisolism. Patients with PBMAH showed greater autonomous cortisol secretion, bigger tumor size, and higher rates of diabetes than those without PBMAH.

Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach.

OBJECTIVE: To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs). METHODS: This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center. RESULTS: Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications. CONCLUSIONS: An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction.

Predictive model of surgical remission in acromegaly: age, presurgical GH levels and Knosp grade as the best predictors of surgical remission.

PURPOSE: To identify presurgical clinical, hormonal and radiological variables associated with surgical remission in acromegaly and develop a predictive model for surgical remission. METHODS: Ambispective study of acromegaly surgical patients followed in two Spanish tertiary hospitals. Patients operated by the same neurosurgeon by endonasal endoscopic transsphenoidal approach (n = 49) were included to develop the predictive model, and patients operated by other neurosurgeons (n = 37) were used for external validation of the predictive model. The predictive model was developed with a multivariate logistic regression model based on the 2000 criteria. RESULTS: 86 acromegalic patients were included. 49 patients, 83.7% with macroadenomas and 32.7% with Knosp grade > 2, were included for the development of the predictive model. The overall rate of surgical remission with the 2000 criteria was 73.5% and 51.0% with the 2010 criteria. Using the 2000 criteria, variables associated with surgical remission were: older age (OR = 1.1, p = 0.001), lower basal presurgical GH levels (OR = 0.9, p = 0.003), Knosp 0-2 (OR = 34.1, p < 0.0001) and lower maximum pituitary adenoma diameter (OR = 0.9, p = 0.019). The model with the best diagnostic accuracy to predict surgical remission combined age, Knosp 0-2 and presurgical GH levels (AIC = 29.7, AUC = 0.95) with a sensitivity of 93.8% and a specificity of 75.0%. The estimated loss of prediction with the external validation (n = 37) was 4.2%. CONCLUSION: The predictive model with the best diagnosis accuracy for surgical remission combined age, Knosp 0-2 and presurgical GH levels, with a sensitivity of 93.8% and a specificity of 75.0%. This model could be very useful to select candidates to preoperative medical treatment and planning the follow-up.

Aerial strategies advance volcanic gas measurements at inaccessible, strongly degassing volcanoes.

Volcanic emissions are a critical pathway in Earth's carbon cycle. Here, we show that aerial measurements of volcanic gases using unoccupied aerial systems (UAS) transform our ability to measure and monitor plumes remotely and to constrain global volatile fluxes from volcanoes. Combining multi-scale measurements from ground-based remote sensing, long-range aerial sampling, and satellites, we present comprehensive gas fluxes-3760 ± [600, 310] tons day-1 CO2 and 5150 ± [730, 340] tons day-1 SO2-for a strong yet previously uncharacterized volcanic emitter: Manam, Papua New Guinea. The CO2/ST ratio of 1.07 ± 0.06 suggests a modest slab sediment contribution to the sub-arc mantle. We find that aerial strategies reduce uncertainties associated with ground-based remote sensing of SO2 flux and enable near-real-time measurements of plume chemistry and carbon isotope composition. Our data emphasize the need to account for time averaging of temporal variability in volcanic gas emissions in global flux estimates.

Postoperative management of patients with pituitary tumors submitted to pituitary surgery. Experience of a Spanish Pituitary Tumor Center of Excellence.

There is a lack of evidence on timing, frequency, and duration of postoperative endocrine, radiologic, and ophthalmologic assessments that should be performed after pituitary surgery (PS). However, it is known that careful optimization of treatment and follow-up strategies as well as a multidisciplinary approach may have a significant impact on long-term outcomes, improving surgical results, minimize complications and facilitate their correct treatment if occurring, and optimize the hormonal, ophthalmological, and radiological reassessment throughout the follow-up. Considering that there are no specific guidelines on the postoperative management of patients with pituitary tumors (PT), we present our protocol for the postoperative management of patients with PT. It has been elaborated by the multidisciplinary team of a Spanish Pituitary Tumor Center of Excellence (PTCE) that includes at least one neurosurgeon, ENT, neuroradiologist, neuro-ophthalmologist, endocrine pathologist and endocrinologist specialized in pituitary diseases. We elaborated this guideline with the aim of sharing our experience with other centers involved in the management of PT thereby facilitating the postoperative management of patients submitted to PS.

Impact of bevacizumab on functional recovery and histology of the liver after resection of colorectal metastases.

BACKGROUND: The impact of bevacizumab on functional recovery and histology of the liver was evaluated in patients undergoing hepatic resection for colorectal liver metastases (CLM) following bevacizumab treatment. METHODS: Consecutive patients who had resection of CLM between July 2005 and July 2009 following preoperative chemotherapy were identified retrospectively from a prospectively collected database. Patients who had received bevacizumab before the last chemotherapy line were excluded. Postoperative liver function and histology were compared between patients with and without bevacizumab treatment. Recorded parameters included serum prothrombin time, total bilirubin concentration, and levels of aspartate and alanine aminotransferase and γ-glutamyltransferase. RESULTS: Of 208 patients identified, 67 had received last-line bevacizumab, 44 were excluded and 97 had not received bevacizumab. Most patients in the bevacizumab group (66 per cent) received a single line of chemotherapy. Bevacizumab was most often combined with 5-flurouracil/leucovorin and irinotecan (68 per cent). The median number of bevacizumab cycles was 8·6 (range 1-34). Bevacizumab administration was stopped a median of 8 (range 3-19) weeks before surgery. There were no deaths. Postoperative morbidity occurred in 43 and 36 per cent of patients in the bevacizumab and no-bevacizumab groups respectively (P = 0·353). The mean(s.d.) degree of tumour necrosis was significantly higher in the bevacizumab group (55(27) versus 32(29) per cent; P = 0·001). Complete pathological response rates were comparable (3 versus 8 per cent; P = 0·307). Postoperative changes in functional parameters and objective signs of hepatic toxicity were similar in both groups. CONCLUSION: Preoperative administration of bevacizumab does not seem to affect functional recovery of the liver after resection of CLM. Tumour necrosis is increased following bevacizumab treatment.

Enseñanza clínica en el laboratorio: un acercamiento desde el discurso docente / Clinical teaching in the lab: An approach from the discourse of the teacher

El tema de la Enseñanza clínica (ECL) sin lugar a duda es un tema relevante en la Enfermería, tanto para el acto mismo de enseñar en la clínica como para los actores: alumnos y docentes. El propósito de la investigación fue explorar la experiencia de los docentes de enfermería con respecto a la ECL en el laboratorio de práctica. Metodología. El diseño fue cualitativo se empleó el método de incidente critico, se basó en entrevistas a profundidad a través de la técnica de grupos focales. El muestreo fue aleatorio. La entrevista se dirigió con una Guía semiestructurada de 7 preguntas. Resultados y Discusión. Se reconocieron las siguientes categorías: a) definición de la ECL, b) enseñanza clínica en el laboratorio:aspectos definitorios y atributos del docente, c) tutoría en la ECL y c) la evaluación de la misma. Los resultados coinciden con la literatura especializada en cuanto a la multideterminación del proceso educativo, sin embargo se muestran aspectos relevantes en cuanto al perfil del docente en enfermería para esta actividad y las vertientes de la evaluación, que para el caso de la ECL tiene matices singulares

Discovery of a cool planet of 5.5 Earth masses through gravitational microlensing.

In the favoured core-accretion model of formation of planetary systems, solid planetesimals accumulate to build up planetary cores, which then accrete nebular gas if they are sufficiently massive. Around M-dwarf stars (the most common stars in our Galaxy), this model favours the formation of Earth-mass (M(o)) to Neptune-mass planets with orbital radii of 1 to 10 astronomical units (au), which is consistent with the small number of gas giant planets known to orbit M-dwarf host stars. More than 170 extrasolar planets have been discovered with a wide range of masses and orbital periods, but planets of Neptune's mass or less have not hitherto been detected at separations of more than 0.15 au from normal stars. Here we report the discovery of a 5.5(+5.5)(-2.7) M(o) planetary companion at a separation of 2.6+1.5-0.6 au from a 0.22+0.21-0.11 M(o) M-dwarf star, where M(o) refers to a solar mass. (We propose to name it OGLE-2005-BLG-390Lb, indicating a planetary mass companion to the lens star of the microlensing event.) The mass is lower than that of GJ876d (ref. 5), although the error bars overlap. Our detection suggests that such cool, sub-Neptune-mass planets may be more common than gas giant planets, as predicted by the core accretion theory.

El jueceo: una experiencia de aprendizaje en la investigación cualitativa / Judging: a learning experience in qualitative research

En las áreas de las ciencias de la salud existe un bagaje teórico-metodológico amplio para abordar los fenómenos de estudio que ahí se presentan, mismo que aporta estrategias de análisis para la particular interpretación de los asuntos de interés disciplinar. La realidad que trata de desentrañar el investigador Enfermero no es unicausal, en ella convergen la dimensión del cuidado y los procesos formativos, tal es el caso que se expone a partir de la metodología cualitativa, donde la Enfermería Mexicana aún tiene mucho que aportar y un gran camino por recorrer. Incursionar en este tipo e metodología, implica la consideración de una gama de habilidades por parte del investigador, sin embargo cuando la experiencia es colectiva se requieren de otras condiciones, que conduzcan a un trabajo grupal y en su momento colegiado. Particularmente el jueceo, obliga a procesos de introyección, sustracción, inducción y deducción, que permiten gestar un escenario común donde se construyen nuevas perspectivas producto del análisis grupal y en donde se reconocen los conceptos que constituyen al fenómeno y sus posibles relaciones. Todo ello en aras de identificar conceptos subyacentes a los discursos que en el caso aportan elementos para la práctica del cuidado de la Enfermería. De este modo, participar en el jueceo en el marco de una tesis de maestrías, es en sí mismo una evidencia de la construcción de experiencias pedagógicas significativas que en el particular se desea socializar.

In the areas of health sciences, there is a comprehensive theoretical-methological baggage for approaching the study of phenomena present there, which contributes the analysis strategies for the particular interpretation of discipline issues of interest. The reality the nurse research intends to work out has not a unique cause, in it converges care dimension and educative processes; such is the case expoused from qualitative methodology, where Mexican nursing still has a lot to contribute and a long way up. Entering into this kin d of methodology, implies taking into account a skill gamut by the researacher; however, when experiencie is collective, other condition are necessary for leading toward a groupal, and at its moment collegiated, task. Particulary judgeing, compels to introyection, sustraction, induction, and deduction processes which allow gestating a common scenery where new perspectives stemed from groupal analyses are constructed, and where concepts that constitute the phenomenon and its posible relations are aknowledged. All this, intended to identifying concepts underlying discourses, that when the case arises, contribute with elements for nursing care practice. In this way, particpating in judgeing within a master´s degree thesis framework is by itself evidencie of the construction of pedagogical significant experiences that are meant to be particulary socialized.

Calibrated serological techniques demonstrate significant different serum response rates to an oral killed cholera vaccine between Swedish and Nicaraguan children.

Serum responses to oral cholera vaccines were assessed in three paediatric vaccine trials, two in León, Nicaragua and one in Stockholm, Sweden. A calibrated anti-cholera toxin B subunit (CTB) IgA ELISA was used together with an assay for vibriocidal antibodies. Swedish children had lower pre-vaccination levels of antibody, but serum responses were more pronounced in Swedish children than in Nicaraguan children. Post-vaccination levels of anti-toxin antibody were generally above those found after natural infections with enterotoxigenic Escherichia coli, that cross-reacts serologically with Vibrio cholerae. Adverse events seen after vaccination were generally mild and of little clinical significance.

[Vitrectomy for asteroid hyalosis]. / Vitrectomía en hialosis asteroidea.

PURPOSE: To evaluate the role of pars plana vitrectomy for asteroid hyalosis and synchisys scintillans with decrease of visual acuity. METHODS: Retrospective study of 15 patients on whom pars plana vitrectomy was performed. We studied the visual acuity before the surgery, the best and the final vision. Risk vascular factors, intraocular pressure, complications during the surgery or in the follow up were determined. RESULTS: We operated on 17 eyes of 15 patients (10 male, 5 female). In 2 cases we added peeling of macular pucker and in two cases a cataract surgery. Average age was 73.8 (standard deviation 8.6); risk vascular factors were found in 66.6%. There weren't any complications during the surgery. Later, 4 cataracts, 3 macular pucker and 1 macular hole (stage IV) developed. The average vision before the surgery was 20/60, the best 20/40 and the final vision 20/50. Average follow up time was 22.8 (s.d. 17.3) months. CONCLUSIONS: Asteroid hialosis was more frequent in elderly males (2/3) and in patients with risk vascular factors (66.6%). Cataract surgery was necessary in 50% of eyes during or after the pars plana vitrectomy. Seventeen percent of eyes presented macular pucker in the follow up. Recovery of vision was less than expected.

Biotransformation of caryophyllene oxide by botrytis cinerea

Biotransformation of caryophyllene oxide (1) with B. cinerea afforded 15 products (2-16). Ten of these (3-5, 7, 9-11, and 14-16) are reported here for the first time. The main reaction paths involved stereoselective epoxidation at C-8/C-13 and hydroxylation at C-7. A rearranged compound was found, which was a cyclization product 16 possessing the caryolane skeleton.

[Knowledge, attitude and practice in relation with HIV/AIDS infection in high-school and vocational training in Mieres]. / Conocimientos, actitudes y conductas en relación con la infección por el VIH/sida en estudiantes de bachillerato y formación profesional de Mieres.

OBJECTIVE: To find the students' level of knowledge, attitudes and conduct concerning HIV/AIDS. INTERVENTIONS: Data-gathering by means of a self-administered questionnaire. RESULTS: 450 students (60.8%), average age 17, took part. 52.9% answered questions on the disease correctly. 48.9% believed they had sufficient knowledge/information. More men than women thought they were well-informed. 89.6% said they would accept someone with AIDS in their class. 65% said they were worried about the possibility of being infected. 31.6% said they were sexually active. All of these affirmed that they knew of and took preventive measures. 83% said they always used a condom, the reason being to avoid pregnancy. 0.9% took intravenous drugs, but have never shared syringes. 100% knew that this protected them from infection. 42% (more men than women) believed that today's youth is changing its life-style because of AIDS. CONCLUSIONS: In spite of knowing the basic facts about HIV/AIDS, students have many mistaken ideas. They do not think that these facts have given rise to changes in their behaviour. These results could be useful for the design of a future health education intervention.

Comparison on the performance of Leishmania major-like and Leishmania braziliensis braziliensis as antigen for New World leishmaniasis IgG-immunofluorescence test.

The performance of an antigen of L. major-like promastigotes for the serological diagnosis of mucocutaneous leishmaniasis in the IgG-immunofluorescent test was compared to that of an antigen of L.braziliensis braziliensis. Each antigen was used to test two hundred and twenty-four sera of etiologies such as mucocutaneous leishmaniasis, deep mycoses, toxoplasmosis, malaria. Chagas' disease, visceral leishmaniasis, anti-nuclear factor, schistosomiasis, rheumatoid factor and normal controls. Agreement between responses to each antigen was high: 77.2% of leishmaniases sera agreed on a positive or a negative result to both antigens and 91.1% of control sera. Cross reactivity was restricted to Chagas' disease sera, visceral leishmaniasis, anti-nuclear factor and paracoccidioidomycosis. The quantitative response of leishmaniasis and Chagas' disease sera to both antigens was evaluated by a linear regression; although the y-intercept and the slope were different for each antigen, neither was better than the other in the disclosure of anti-Leishmania antibodies. In the case of Chagas' disease sera the L.major-like antigen was better than L.b.braziliensis' to disclose cross-reacting antibodies.