High-sensitivity troponin T and the risk of recurrent readmissions after hospitalisation for acute heart failure. / Troponina T de alta sensibilidad y riesgo de hospitalizaciones recurrentes tras un ingreso por insuficiencia cardíaca aguda.

OBJECTIVES: High-sensitivity troponin is a biomarker of myocardial damage and is associated with a greater risk of mortality and disease progression in patients with acute heart failure (AHF). However, its relationship with the risk of future readmissions is less known. The aim of this study was to assess the association between ultrasensitive troponin T (TnT-us) values in patients with AHF and the risk of recurrent readmissions in the follow-up. METHODS: We prospectively included a cohort of 621 consecutive patients with AHF, excluding those patients with acute coronary syndrome. We measured the TnT-us levels obtained during the first medical contact in the emergency department. The risk of cumulative readmissions was assessed using negative binomial regression. RESULTS: The mean age of the participants was 73.6±10.8 years, 54.6% were men, and 52% had a left ventricular systolic function ≥50%. The median TnT-us level was 35.5pg/ml (interquartile range [IQR], 22-67). After a median follow-up of 1.2 years (IQR, 0.4-2.4), a total of 153 deaths (24.6%) were recorded, as well as 689 readmissions for all causes in 303 patients (48.8%) and 286 readmissions for HF in 163 patients (26.3%). In the multivariate analysis, the high TnT-us values were associated with an increased risk of readmission, both for all causes and for HF (incidence rate ratio [IRR], 1.16; 95% confidence interval, 1.02-1.36; p=.029 and IRR, 1.23; 95% confidence interval, 1.04-1.46; p=.018, respectively). CONCLUSIONS: For patients with AHF, the increase in TnT-us levels was independently associated with a risk of recurrent readmissions during the follow-up.

Endometriosis peritoneal masiva asociada a gran elevación de CA-125: discrepancia entre hallazgos y clínica / Massive peritoneal endometriosis associated with high elevation of CA-125: discrepancy between findings and symptoms

ANTECEDENTES: Frecuentemente, las pacientes con endometriosis presentan una elevación de marcadores tumorales Ca 125 y Ca 19.9. No obstante, no existe correlación clara con la expresión clínica ni con el grado de afectación. En algunos casos, es necesario un diagnóstico diferencial con patologías malignas. CASO CLÍNICO: Mujer de 29 años con clínica aislada de dismenorrea moderada y hallazgo de masas ováricas bilaterales con elevación intensa de marcadores tumorales: Ca-125: 7.716 U/mL y Ca-19.9: 995 U/mL. Se decide intervención quirúrgica laparoscópica evidenciándose endometriosis ovárica y extensión peritoneal masiva con afectación de peritoneo parietal abdominal, superficie uterina, fondo de Douglas, parametrios, vejiga, hemidiafragma derecho, hígado y serosa intestinal. Se realiza adhesiolisis cuidadosa, quistectomía y extirpación de múltiples implantes endometriósicos en cavidad abdominal. Se observó un descenso de los marcadores a las 48 horas: Ca-125 de 253 U/mL y Ca 19.9 de 4,9 U/mL, ambos negativos al mes de la cirugía. CONCLUSIÓN: Una elevación intensa de los marcadores tumorales precisa de diagnóstico diferencial en el contexto de la endometriosis. Existe una gran discrepancia entre los valores de los marcadores tumorales con la clínica y severidad de la endometriosis. Los hallazgos quirúrgicos son fundamentales, evidenciando una afectación masiva subdiagnosticada hasta la cirugía.

BACKGROUND: Frequently, patients with endometriosis present elevated tumor marker Ca 125 and Ca 19.9. However, there is no clear correlation with the clinical expression or the degree of involvement. In some cases, differential diagnosis is necessary with malignancies. CASE REPORT: A 29 year old woman with moderate dysmenorrhea and finding of bilateral ovarian masses with intense elevation of tumor markers, CA125: 7,716 U/mL and Ca-19.9: 995 U/mL. Laparoscopic surgery is decided evidenced massive ovarian endometriosis and peritoneal extension with involvement of abdominal peritoneum, uterine surface, Douglas, parametrium, bladder, right hemidiaphragm, liver and intestinal serosa. Careful liberation of adherences, ovarian cystectomy and removal of multiple endometriosic implants. A decrease of tumor markers was observed at 48 hours (Ca-125: 253 U/mL and Ca-19.9: 4.9 U/mL), and negative one month after surgery. CONCLUSION: An intense elevated tumor markers accurate differential diagnosis in the context of endometriosis. There is a large discrepancy between the values of tumor markers with clinical and severity of endometriosis.

Fractura - hundimiento craneal congénita: una realidad obstétrica / Congenital depressed skull fracture: an obstetric reality

Las fracturas craneales congénitas tienen baja incidencia, de una etiología desconocida, generando una gran alarma respecto a la actuación obstétrica en el momento del parto. Se presenta el diagnóstico, exploración radiológica y evolución clínica de dos recién nacidos con fractura-hundimiento craneal intrauterina, uno de ellos con manejo expectante y el otro con manejo quirúrgico. Ambos con buena evolución posterior y sin secuelas neurológicas ni estéticas.

The congenital skull fractures presented a low incidence, unknown aetiology, and it causes great alarm as far as the obstetric actions to be taken at birth are concerned. This work presents the diagnosis, radiology examinations and clinical evolution of two live-born infants with an intrauterine depressed skull fracture, one with expectant management and the other with surgical management. Both neonates showed good subsequent evolution with no neurological and no aesthetic sequelae.

Clinically important molecular features of Peruvian colorectal tumours: high prevalence of DNA mismatch repair deficiency and low incidence of KRAS mutations.

BACKGROUND: The incidence of colorectal cancer (CRC) in Peru has been increasing, and no data have been published on the molecular features. We explored the most relevant genetic events involved in colorectal carcinogenesis, with clinical implications. METHODS: Using immunohistochemistry for mismatch-repair (MMR) proteins (MLH1, MSH2, MSH6, and PMS2) and microsatellite instability analysis, we evaluated the status of 90 non-selected CRC Peruvian patients followed in a nationwide reference hospital for cancer (INEN, Lima). Tumours with loss of hMLH1 were evaluated further for hMLH1 promoter hypermethylation and all cases were evaluated for the presence of KRAS and BRAF-V600E mutations. RESULTS: MMR deficiency was found in 35 (38.8%) patients. We identified an unexpected association between MMR deficiency and older age. Among the 14 cases with loss of MLH1, 10 samples exhibited hypermethylation. Of the 90 cases evaluated, 15 (16.7%) carried KRAS mutations; we found one previously unreported mutation (G13R). CONCLUSIONS: Peruvian CRC tumours exhibited the highest prevalence of MMR deficiency reported to date. The expected hereditary component was also high. The age of onset of these MMR deficient tumours was greater than that observed for non-MMR deficient cases, suggesting the ineffectiveness of the Bethesda criteria for Lynch syndrome screening in Peru. Prospective studies are warranted to define the molecular characteristics of CRC in this population.

[Perforation of the acalculous gallbladder in a renal transplant recipient with CMV infection]. / Perforacion de vesicula biliar en el se-no de una infeccion por citomegalovirus en trasplante renal.

We report the case of a renal transplant recipient who developed acute acalculous cholecyscitis resulting in gallbladder perforation. At admission CMV antigenemia was negative. Emergency laparatomy was performed and showed the gallbladder to be infarted with a perforation. The abdominal cavity contained two litres of sterile bilious fluid. The pathological report showed frequent endothelial cells contained intranuclear and intracitoplasmatic inclusion (fig. 1). Treatment with Ganciclovir iv was started after diagnosis, but a computerized tomography scan demonstrated severe acute pancreatitis (grade E. Baltazar). The patient developed multiorgan failure and died on 19th day after surgery. Necropsy showed cytomegalic inclusions in pancreas (fig. 2), gastrointerstinal tract, lung and graft. A necroticing pneumonia with Mycotic spores and hiphae was seen. Aspergillus was also observed in myocardium (fig. 3).

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) treated with 2-chlorodeoxyadenosine.

Sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai-Dorfman disease (RDD) is a rare but well-defined histiocytic proliferative disorder of unknown etiology that usually presents with cervical lymphadenopathy, fever, leukocytosis, and hypergammaglobulinemia in an otherwise healthy child. Although many patients undergo spontaneous remission, a subset of patients with systemic disease has a more serious course. For those patients with a poor outcome, steroids and chemotherapeutic agents such as etoposide or 6-mercaptopurine plus low dose methotrexate have been used. We present a child with a massive cervical lymphadenopathy treated with 2-chlorodeoxyadenosine (2-CdA, cladribine) after other approaches failed.

Mismatch repair status in the prediction of benefit from adjuvant fluorouracil chemotherapy in colorectal cancer.

AIM: Some retrospective studies have shown a lack of benefit of 5-fluorouracil (5-FU) adjuvant chemotherapy in patients with mismatch repair (MMR) deficient colorectal cancer. Our aim was to assess if this molecular marker can predict benefit from 5-FU adjuvant chemotherapy. A second objective was to determine if MMR status influences short term survival. METHODS: We included 754 patients with a median follow up of 728.5 days (range 1-1097). A total of 260 patients with stage II or III tumours received 5-FU adjuvant chemotherapy, according to standard clinical criteria and irrespective of their MMR status. A tumour was considered MMR deficient when either BAT-26 showed instability or there was loss of MLH1 or MSH2 protein expression. RESULTS: At the end of the follow up period, 206 patients died and 120 presented with tumour recurrence. Sixty six (8.8%) patients had MMR deficient tumours. There were no significant differences in overall survival (MMR competent 72.1%; MMR deficient 78.8%; p = 0.3) or disease free survival (MMR competent 61.3%; MMR deficient 72.3%; p = 0.08). In patients with stage II and III tumours, benefit from 5-FU adjuvant chemotherapy was restricted to patients with MMR competent tumours (overall survival: chemotherapy 87.1%; non-chemotherapy 73.5%; log rank, p = 0.00001). Patients with MMR deficient tumours did not benefit from adjuvant chemotherapy (overall survival: chemotherapy 89.5%; non-chemotherapy 82.4%; log rank, p = 0.4). CONCLUSIONS: Benefit from 5-FU adjuvant chemotherapy depends on the MMR status of tumours in patients with colorectal cancer. 5-FU adjuvant chemotherapy improves survival in patients with MMR competent tumours but this benefit from chemotherapy cannot be extended to patients with MMR deficient tumours.

Mesectodermal leiomyoma of ciliary body.

A 37-year-old woman had a mass in her left ocular globe. Uveal melanoma was suspected and enucleation was performed. Microscopically, the lesion proved to be a typical case of mesectodermal leiomyoma of the ciliary body. According to some authors, the peculiar neural appearance of this tumor could be the reflection of its probable origin from mesectodermal smooth muscle. Immunohistochemical analysis showed reactivity for muscle-specific actin and negativity for desmin, S-100 protein, HMB-45, EMA, and GFAP. Our results do not support the proposed neuroectodermical origin of this tumor, since coexpression of muscular and neural markers was not observed.

[Impact of medical counselling on giving up smoking during pregnancy]. / Impacto del consejo médico para dejar de fumar durante la gestación.

OBJECTIVE: Women s tobacco consumption has increased in Spain in recent years, especially among women of reproductive age. This study aims to evaluate the impact of medical counselling integrated into pre-natal care on tobacco consumption during pregnancy and the period after delivery. DESIGN: Quasi-experimental intervention study.Setting. Hospital del Mar, Barcelona. PATIENTS: 219 patients who attended the Hospital del Mar for delivery during 1996 (control group) and 169 patients seen during their pregnancies at the same hospital in 1997 (intervention group). INTERVENTIONS: The control group patients had received normal care. The pregnant women in the intervention group received systematic structured counselling on giving up smoking, backed up by a special brochure composed for this purpose. MEASUREMENTS AND RESULTS: The intervention and control groups showed no statistically significant differences either in their social or demographic variables or in their tobacco consumption. In both groups the evolution of their smoking during pregnancy was determined during their pre-natal visits and six months after delivery through a telephone interview. 44 of the women in the control group (20.1%) gave up smoking before their first pre-natal visit, and 11 (5%) gave up during pregnancy. In the intervention group 26 (17.7%) had given up spontaneously and 16 (10.9%) gave up during pregnancy. Of those who gave up completely during pregnancy, 36.4% of women in the control group and 64.3% in the intervention group remained abstinent at six months (P=.002). CONCLUSIONS: Counselling at pre-natal check-ups to give up smoking lightly increases the number of women who give up and reduces significantly the number of post-delivery backsliders.

[Perinatal cytomegalovirus infection in preterm infants]. / Infección perinatal por citomegalovirus en recién nacidos pretérmino.

OBJECTIVE: To study the incidence of perinatal cytomegalovirus infection in neonates admitted to our hospital in the last three years, as well as the mode of transmission, serologic and microbiologic data, and the clinical outcome of these infants. METHODS: We performed a retrospective study by reviewing the medical records of neonates with a diagnosis of cytomegalovirus infection. RESULTS: Twenty-four neonates received this diagnosis. Of these, 21 (85 %) were premature infants with a birthweight of less than 1500 gr, representing 6 % of all neonates with this birthweight hospitalized during the study period. The percentage of transfusion and breastfeeding was high (87 % and 91 %, respectively) and consequently the route of transmission could not be identified. Nine neonates (34 %) presented associated hepatic dysfunction and three (12 %) developed severe disease requiring antiviral treatment. CONCLUSIONS: Perinatal cytomegalovirus infection is frequent in preterm infants and may be serious. It is important to detect cytomegalovirus infections and to develop preventive methods.

[Toxic hepatitis associated with tamoxifen use. A case report and literature review]. / Hepatitis tóxica asociada al uso de tamoxifeno. Presentación de un caso y revisión bibliográfica.

Tamoxifen is an antiestrogenic drug that acts by binding to the estrogen receptor. The drug is used as a co-adjuvant treatment in advanced breast cancer expressing the oestrogen-receptor protein. Clinical trials of tamoxifen have shown its efficacy in reducing mortality and recurrence rates over a five-year treatment. Cases of tamoxifen-associated hepatotoxicity have been described, including cholestasis with or without cytolysis and steatohepatitis. We report the case of a female patient who developed hepatic alterations while undergoing continuous tamoxifen treatment. We also present an overview of similar cases published to date and comment on the advisability of continuing or suppressing this treatment in patients with hepatotoxicity or after a five-year treatment period.

Human immunodeficiency virus infection in pregnant women, transmission and zidovudine therapy.

OBJECTIVE: To determine the rate of mother to child transmission of HIV infection in women treated with zidovudine (ZDV). PATIENTS AND METHODS: A consecutive series of 52 HIV-positive pregnant women who either received antenatal care or delivered at our institution. Forty-three women were known to be HIV positive before delivery. Forty were treated with ZDV, 36 intravenously. Twelve had no antenatal care and one refused antenatal treatment. All neonates were treated with ZDV. RESULTS: The HIV transmission rate in children born to mothers treated with ZDV was 6.6%. This compares with a transmission rate of 14% before we used ZDV. All three mothers who transmitted infection had low compliance, initiated therapy late in pregnancy or had advanced disease. CONCLUSION: Our experience supports the idea that ZDV treatment has reduced HIV transmission rate.